Resistance Training Does Not Decrease Placental Blood Flow During Valsalva Maneuver: A Novel Use of 3D Doppler Power Flow Ultrasonography

BACKGROUND

The Valsalva maneuver may increase maternal blood pressure and intra-abdominal pressure, resulting in decreased blood flow to the fetus during resistance training.

HYPOTHESIS

There is no significant reduction in placental blood flow in pregnancy during resistance training in recreational athletes, as documented by a 3-dimensional power flow Doppler ultrasonography.

STUDY DESIGN

Cohort.

LEVEL OF EVIDENCE

Level 3.

METHODS

A cohort of healthy women who participated in recreational athletics was enrolled in a prospective study to assess placental blood flow during a resistance exercise. A 1 repetition maximum (1RM, up to 50 lb) was determined through a modified chest press as a marker of heavy resistance training. Three-dimensional volume measurements and power Doppler flow were determined at the rest phase and during the 1RM lift phase. The vascular flow index (VFI) was calculated to determine placental perfusion during each phase.

RESULTS

A total of 22 women participated. The mean age of participants was 31 years. Gestational age ranged from 13 to 28 weeks. Average 1RM weight lifted was 30 lb. Four women (18%) were able to lift 50 lb, the maximum weight that the study allowed. The remaining 18 women (82%) lifted their true 1RM. Mean VFI during lift phase was 2.185 compared with 2.071 at rest (P = 0.03). There was a slight mean increase in VFI during lift phase, 0.114 (95% CI 0.009-0.182) from 2.071 to 2.185 with lifting (P = 0.03). The 15 women who participated in structured exercise had a mean VFI at rest and during the lift phase of 2.031 and 2.203, respectively (P = 0.01).

CONCLUSION

Three-dimensional power flow Doppler imaging can guide resistance training during pregnancy to prevent fetal injury due to hypoperfusion. Resistance training up to an RM1 of 50 lb did not result in a significant reduction of placental blood flow from resting state in the study population.

CLINICAL RELEVANCE

This technique may be used to guide training parameters among pregnant athletes.

Deepithelialized glans reconfiguration (DeGRe) for distal hypospadias repair

INTRODUCTION

Our objective was to present our experience with a novel technique for distal hypospadias repair consisting of deepithelialized glans reconfiguration.

PATIENTS AND METHOD

We reviewed the clinical data of all patients who underwent distal hypospadias using Deepithelialized Glans Reconfiguration between January 2015 and December 2019. We noted age at surgery, position of meatus, duration of urethral catheterization and hospitalization, as well as early and late complications. Standard postoperative care included follow-up examination at 1, 6 and 12 months. Successful repair was defined as a patient presenting with a straight penis with an apical meatus, no stricture nor fistula.

RESULTS

Sixty-seven patients were included. Average age at surgery was 12.5 months (6-23 months). All patients presented distal hypospadias (3 glanular, 61 coronal, 3 subcoronal). 36% of patients were operated as day case surgery. No intra-operative complications were recorded. Eleven patients did not complete the designated follow up. They attended the post-operative appointment at six months but not the one-year visit. All patients presented satisfactory urinary streams according to the parents. All parents were satisfied with the cosmetic appearance of their child's penis. Two patients presented with glans dehiscence (3%). The mean HOPE score for the last 10 patients was 47.4 ± 3.2 out of a maximum of 50.

DISCUSSION

Deepithelialized Glans Reconfiguration is a simple technique with satisfactory results. Though it has similarities with existing techniques, it contains specific aspects not described previously. Contrary to the MAGPI technique, there is no meatal advancement, no rotation of the glans wings, and it is the glans lateral and proximal to the meatus which is approximated in the midline. As opposed to the GAP procedure, there is no closure of the ventral aspect of the urethra. We rely on secondary healing within the glans to reconstruct the missing ventral aspect of the urethra. We reserve this technique for coronal hypospadias with a wide, deep glanular groove. Deepithelialization favours rapid healing of the glans wings on the midline. There is no formal urethroplasty. The limits to this study include lack of long-term (>1 year) follow-up and uroflow. Though careful observation did not identify fistulas, the absence of functional stenosis has to be more clearly evaluated at a later age. Finally, this technique is not suitable for the completely flat glans as it relies on being able to approximate the glans ridges in the midline.

CONCLUSION

Deepithelialized Glans Reconfiguration is a simple technique which achieves good cosmetic results, without complications associated with meatal or urethral advancement or formal urethroplasty.

Perinatal Outcomes in Women with a History of Recurrent Pregnancy Loss

OBJECTIVE

This study aimed to evaluate perinatal outcomes in women with a history of recurrent pregnancy loss.

STUDY DESIGN

Retrospective cohort study of singleton and nonanomalous gestations at ≥ 20 weeks who delivered at our academic institution. The exposed group was defined as women with a history of ≥ 2 consecutive spontaneous abortions (SABs) at < 12 weeks. These women were compared with women with a history of ≤ 1 SAB at < 12 weeks. The primary outcome was preterm birth (PTB) at < 37 weeks. Secondary outcomes included gestational age at delivery, gestational diabetes, small for gestational age birth weight, hypertensive diseases of pregnancy, fetal demise, cesarean delivery, and a composite of neonatal complications (5-minute Apgar score < 5, perinatal death, and NICU admission). Multivariable logistic regression was performed to adjust for confounders.

RESULTS

Of 17,670 women included, 235 (1.3%) had a history of ≥ 2 consecutive SABs. Compared with women with a history of ≤ 1 SAB, women with ≥ 2 consecutive SABs were not more likely to have a PTB (19.6 vs. 14.0%, p = 0.01, adjusted odds ratios (AOR): 0.91, 95% confidence interval [CI]: 0.62-1.33). However, they were more likely to deliver at an earlier mean gestational age (37.8 ± 3.4 vs. 38.6 ± 2.9 weeks, p < 0.01) and to have gestational diabetes (12.3 vs. 6.6%, p < 0.01, AOR: 1.69, 95% CI: 1.10-2.59). Other outcomes were similar between the two groups.

CONCLUSION

A history of ≥ 2 consecutive SABs was not associated with an increased incidence of PTB but may be associated with gestational diabetes in a subsequent pregnancy.

KEY POINTS

· This was a retrospective cohort study.. · Women with a history of recurrent pregnancy loss (RPL) were studied.. · RPL was associated with an increase in preterm birth..

Long-term clinical, virological and immunological outcomes following planned treatment interruption in HIV-infected children

OBJECTIVES

Planned treatment interruption (PTI) of antiretroviral therapy (ART) in adults is associated with adverse outcomes. The PENTA 11 trial randomized HIV-infected children to continuous ART (CT) vs. CD4-driven PTIs. We report 5 years' follow-up after the end of main trial.

METHODS

Post-trial, all children resumed ART. Clinical, immunological, virological and treatment data were collected annually. A sub-study investigated more detailed immunophenotype. CT and PTI arms were compared using intention-to-treat. Laboratory parameters were compared using linear regression, adjusting for baseline values; mixed models were used to include all data over time.

RESULTS

In all, 101 children (51 CT, 50 PTI) contributed a median of 7.6 years, including 5.1 years of post-trial follow-up. Post-trial, there were no deaths, one pulmonary tuberculosis and no other CDC stage B/C events. At 5 years post-trial, 90% of children in the CT vs. 82% in the PTI arm had HIV RNA < 50 copies/mL (P = 0.26). A persistent increase in CD8 cells was observed in the PTI arm. The sub-study (54 children) suggested that both naïve and memory populations contributed to higher CD8 cells following PTI. Mean CD4/CD8 ratios at 5 years post-trial were 1.22 and 1.08 in CT and PTI arms, respectively [difference (CT - PTI) = -0.15; 95% CI: -0.34-0.05), P = 0.14]. The sub-study also suggested that during the trial and at early timepoints after the end of the trial, reduction in CD4 in the PTI arm was mainly from loss of CD4 memory cells.

CONCLUSIONS

Children tolerated PTI with few long-term clinical, virological or immunological consequences.

Effect of Prophylactic Negative Pressure Wound Therapy vs Standard Wound Dressing on Surgical-Site Infection in Obese Women After Cesarean Delivery: A Randomized Clinical Trial

IMPORTANCE

Obesity increases the risk of both cesarean delivery and surgical-site infection. Despite widespread use, it is unclear whether prophylactic negative pressure wound therapy reduces surgical-site infection after cesarean delivery in obese women.

OBJECTIVE

To evaluate whether prophylactic negative pressure wound therapy, initiated immediately after cesarean delivery, lowers the risk of surgical-site infections compared with standard wound dressing in obese women.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized trial conducted from February 8, 2017, through November 13, 2019, at 4 academic and 2 community hospitals across the United States. Obese women undergoing planned or unplanned cesarean delivery were eligible. The study was terminated after 1624 of 2850 participants were recruited when a planned interim analysis showed increased adverse events in the negative pressure group and futility for the primary outcome. Final follow-up was December 18, 2019.

INTERVENTIONS

Participants were randomly assigned to either undergo prophylactic negative pressure wound therapy, with application of the negative pressure device immediately after repair of the surgical incision (n = 816), or receive standard wound dressing (n = 808).

MAIN OUTCOMES AND MEASURES

The primary outcome was superficial or deep surgical-site infection according to the Centers for Disease Control and Prevention definitions. Secondary outcomes included other wound complications, composite of surgical-site infections and other wound complications, and adverse skin reactions.

RESULTS

Of the 1624 women randomized (mean age, 30.4 years, mean body mass index, 39.5), 1608 (99%) completed the study: 806 in the negative pressure group (median duration of negative pressure, 4 days) and 802 in the standard dressing group. Superficial or deep surgical-site infection was diagnosed in 29 participants (3.6%) in the negative pressure group and 27 (3.4%) in the standard dressing group (difference, 0.36%; 95% CI, -1.46% to 2.19%, P = .70). Of 30 prespecified secondary end points, 25 showed no significant differences, including other wound complications (2.6% vs 3.1%; difference, -0.53%; 95% CI, -1.93% to 0.88%; P = .46) and composite of surgical-site infections and other wound complications (6.5% vs 6.7%; difference, -0.27%; 95% CI, -2.71% to 2.25%; P = .83). Adverse skin reactions were significantly more frequent in the negative pressure group (7.0% vs 0.6%; difference, 6.95%; 95% CI, 1.86% to 12.03%; P < .001).

CONCLUSIONS AND RELEVANCE

Among obese women undergoing cesarean delivery, prophylactic negative pressure wound therapy, compared with standard wound dressing, did not significantly reduce the risk of surgical-site infection. These findings do not support routine use of prophylactic negative pressure wound therapy in obese women after cesarean delivery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03009110.

Adherence to Guideline-Based Antibiotic Prophylaxis in Gynecology among Alabama Providers

OBJECTIVES

Surgical site infection (SSI) is a preventable cause of postoperative morbidity. The appropriate use of perioperative antibiotics for prevention of SSIs is a well-established quality metric. Little is known about the adherence to guidelines-based antibiotic prophylaxis among Alabama obstetricians and gynecologists. Our aims were to determine their adherence to guidelines-based antibiotic prophylaxis and identify the factors that are predictive of nonadherence.

METHODS

Online, self-administered survey of Alabama obstetricians and gynecologists.

RESULTS

Providers reported not providing the indicated antibiotics and/or giving nonindicated antibiotics in almost all surgical scenarios. The exceptions included hysterectomies, in which almost all (96%) providers routinely gave indicated antibiotics. No providers reported giving antibiotics during intrauterine device placement or endometrial biopsies, which is appropriate. The only factor predictive of inappropriate antibiotic use was the absence of a standing antibiotic protocol.

CONCLUSIONS

Alabama gynecologic surgeons can and should improve their compliance with guidelines-based antibiotic prophylaxis. More research is needed to determine which interventions would improve adherence in this provider population; our study suggests that the implementation of a standing antibiotic protocol may be a reasonable first step.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Cytomegalovirus seropositivity is independently associated with cardiovascular disease in non-dialysis dependent chronic kidney disease

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of early death in patients with chronic kidney disease (CKD). Previous work has described an association between Cytomegalovirus (CMV) seropositivity and CVD amongst patients with dialysis dependent end stage renal disease. Whether CMV seropositivity is associated with CVD in non-dialysis dependent CKD has not been established.

AIM

Investigate whether past CMV infection is associated with prevalent CVD in patients with non-dialysis dependent CKD.

DESIGN

A retrospective observational study using the Renal Impairment in Secondary Care cohort, a study evaluating bio-clinical determinants of outcomes in patients with progressive CKD.

METHODS

We assayed cryopreserved serum samples collected at inception for anti-CMV IgG antibodies from 764 patients with stages 2 to 5 CKD (pre-dialysis) and investigated its relationship with prevalent CVD.

RESULTS

Median estimated glomerular filtration was 24 ml/min/1.73 m2 (IQR 19-32). Sixty-eight percent of patients were CMV seropositive. CMV seropositivity was associated with older age, non-Caucasian ethnicity, diabetes and higher social deprivation index score. On univariable analysis, CMV seropositivity correlated with higher systolic blood pressure (P = 0.044), prevalent CVD (P < 0.001), ischaemic heart disease (P < 0.001) and cerebrovascular disease (P = 0.022). On multivariable analysis, CMV seropositive patients nearly twice as likely to have CVD compared to seronegative patients [Odds Ratio (OR) = 1.998, CI 1.231-3.242, P = 0.005].

CONCLUSIONS

In patients with non-dialysis CKD, CMV seropositivity is independently associated with a higher prevalence of CVD.

Evidence-based medicine III: level of evidence

The present article is the third installment in a five-part series related to evidence-based medicine (EBM) provided by the European Society for Paediatric Urology Research Committee. It will present the different levels of evidence (i.e. systematic review, randomized controlled trial, cohort study) available to clinicians and researchers and describe the strengths of each study type. While EBM provides a valuable construct to aid in medical decision-making, it remains imperative that this information be interpreted and applied in the clinical context with a good dose of common sense.

Evidence Based Medicine IV: how to find an evidence-based answer to a clinical question? Make a critically appraised topic!

This manuscript is the fourth in a five part series related to evidence based medicine (EBM) provided by the European society of pediatric urology (ESPU) research committee. It will present a way to come to a quick and critical appraisal of available evidence on a specific topic: a CAT (critically appraised topic). The way how to write a cat is described for interventions to be compared to a control group, and for other, more generalized clinical questions. While systematic reviews provide a throughout overview of all evidence available, a CAT provides a shorter way to come to quick insights based on EBM.

EBM II: How to perform a literature search

The present article is a second part related to evidence based medicine (EBM) in a series of five by the European society for paediatric urology (ESPU) research committee. It will present the different databases/search engines available to clinicians and researchers and describe strategies to focus the search to one's particular needs. Indeed, databases/search engines used and search strategy should vary according to the goal of the research. If the aim is to address a clinical problem, the search should allow to identify a small number of most pertinent articles (high specificity); if the search is for research purposes, instead, it should ensure no meaningful articles are overlooked (high sensitivity).

Seropersistence and booster response following vaccination with FSME-IMMUN in children, adolescents, and young adults

BACKGROUND

Tick-borne encephalitis (TBE) is a viral disease that can have a severe clinical course and considerable long-term morbidity. As no curative treatment exists, vaccination is the primary means of prevention. Long-term antibody seropersistence 2-5 years after the 3-dose primary immunization and 3-10 years after first booster was evaluated, as well as booster responses in children, adolescents and young adults.

METHODS

Subjects who participated in these phase 4 prospective, open-label follow-up studies received all vaccinations with FSME-IMMUN. After 3-dose primary immunization, subjects were followed for 2-5 years. Overall, 205 out of 358 subjects (57%) received the first booster and 179 of these subjects (87%) enrolled in a further 10-year follow-up. Antibody seropersistence was assessed annually. Subjects with a TBE antibody titer below a pre-specified cut-off at the yearly blood draw received a booster. Seropositivity rates and geometric mean fold rises (GMFRs) were assessed.

RESULTS

In children who received their 3-dose primary immunization between 1 and 15 years of age, the seropositivity rate 5 years after the 3rd dose was 84.9% by NT and 72.0% by ELISA. One month post-first booster, all subjects were seropositive by NT and 98.5% by ELISA. Response to first booster by GMFR ranged from 3.7 to 11.4. At 5 years post-first booster, seropositivity was 99.4% by NT and 97.5% by ELISA, and at 10 years, was 90.3% by NT and 87.7% by ELISA. Although seropositivity rates differed between age groups, all subjects (100%) who received a second booster responded with a robust increase of TBEV antibodies.

DISCUSSION

Long-lasting seropersistence of TBEV antibodies after the 3-dose primary immunization and first booster was demonstrated as well as a competent immune memory response in those who received a first or second booster at any time during the 15-year follow-up. Therefore, an extension of FSME-IMMUN booster interval up to 10 years after the 3-dose primary immunization seems warranted. ClinicalTrials.gov Identifier: NCT00894686.

Antibiotic Prophylaxis for Cesarean Delivery Among Alabama Providers

OBJECTIVES

A multicenter, randomized controlled trial has demonstrated the benefit of adding azithromycin to routine preoperative antibiotics in unscheduled cesarean deliveries (CDs) to prevent surgical site infections. We sought to describe and identify barriers to the implementation of azithromycin prophylaxis for CDs by Alabama healthcare providers.

METHODS

We conducted an online, self-administered survey of obstetrics and gynecology (OB/GYN) providers in Alabama. E-mail addresses were obtained from a publicly available list. We sent an invitation to complete an anonymous online survey to 478 providers after excluding incompatible addresses and providers who previously opted out of the survey platform. After the initial survey, three reminders to complete the survey were sent. Standard questions regarding population and provider demographics were asked. We assessed timing, duration, and type of antibiotic used for scheduled cesareans and unscheduled (labor) cesareans, and the reasons for not using azithromycin for prophylaxis. Results were compared using the Student t test and χ² test as appropriate.

RESULTS

Of the 66 OB/GYN providers who responded to the survey, 44 (66.7%) performed CDs. Most providers (59.1%) identified as female, served a mix of urban and rural communities (54.5%), and performed deliveries at a level IV hospital (54.5%) with >2000 deliveries annually (52.3%). Most providers (77.3%) reported that an antibiotic stewardship committee supervised antibiotic use at their hospital. For unscheduled cesareans, 54.5% reported the use of azithromycin and 47.7% for scheduled cesareans. The most common reason for not currently using azithromycin was being unaware of evidence for its use (55.6%). The only factors associated with azithromycin use were the urban/rural mix of the provider's patient population (P = 0.03) and the hospital level (P < 0.01). More providers serving a primarily urban population reported azithromycin use (87.5%) compared with those serving in a rural (33.3%) or mixed (47.6%) population. In addition, 74.2% of the obstetricians who delivered in a level 3 or 4 hospital reported using azithromycin prophylaxis, whereas only 22.2% of level 1 or 2 hospital providers reported this usage.

CONCLUSIONS

Only 56.8% of Alabama obstetrics providers reported using azithromycin for CD, which is both effective and cost saving for prevention of surgical site infections. More needs to be done to increase awareness of these benefits.

Fellow Perceptions of Residency Training in Obstetrics and Gynecology

OBJECTIVE

To evaluate the perceptions of current and former fellows in obstetrics and gynecology (OBG) subspecialties of their readiness for fellowship training.

METHODS

A previously used survey was modified and distributed in 2016 to current and former fellows in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology-infertility, and female pelvic medicine and reconstructive surgery. The survey explored domains of professionalism, independent practice, psychomotor ability, clinical evaluation, and scholarship. A standard Likert scale was employed and domains/responses were tailored to each subspecialty. Standard statistical models were utilized.

RESULTS

A total of 478 fellows responded to the survey. Nearly 75% of fellows from each specialty reported feeling prepared or very prepared for fellowship. More than 65% of fellows from each specialty reported feeling very prepared to perform core surgical procedures. More than 90% of respondents reported having opportunities during residency to independently develop a plan of action for patients on labor and delivery. Fewer respondents reported opportunities to independently manage postoperative complications-40.7% of gynecologic oncology and 44.7% of female pelvic medicine and reconstructive surgery reported having such opportunities, whereas 91.9% of maternal-fetal medicine respondents reported having had such opportunities. While 46.4% of respondents received education on scientific writing during residency, 80% reported writing a manuscript as a resident.

CONCLUSIONS

The majority of current and former fellows in OBG subspecialties report feeling prepared for fellowship in terms of clinical and surgical skills. Their feedback reveals opportunities for improvement of independent practice in gynecologic scenarios, as well as formal education on scientific research, for OBG residencies.

An Evaluation of Birth Outcomes in Overweight and Obese Pregnant Women Who Exercised during Pregnancy

It is well established that exercise has numerous health benefits, especially in regard to weight management for the obese and overweight population. However, there is limited data to support the safety or effects of exercise in the obese and overweight pregnant population despite the fact that exercise and weight management in this demographic is particularly important. In an effort to establish the safety profile of exercise during pregnancy in this population, we tested the hypothesis that exercise would not result in adverse birth outcomes. We surveyed postpartum women with an average BMI of 34.7 regarding their participation in exercise during pregnancy. Our primary outcome of interest was small for gestational age (SGA). Secondary outcomes included gestational age at delivery, mode of delivery, head circumference, length and birthweight as compared to those who did not exercise. SGA occurred in 12.5% of women who exercised in the first trimester compared to 14.9% in those who did not exercise (p = 0.678). Similar results were seen for women who exercised in the second and third trimesters. Intensity of exercise did not alter these findings and the analysis of secondary outcomes also did not demonstrate a difference between the groups. In conclusion, overweight and obese women who reported exercising during pregnancy did not have a higher incidence of SGA infants. Exercise should not be discouraged in pregnant women due to obesity.