VaNoLaH trial: a study protocol-a multinational randomised controlled trial including two identical substudies comparing vaginal versus vNOTES (vaginal natural orifice transluminal surgery) hysterectomy or laparoscopic versus vNOTES hysterectomy

INTRODUCTION

Hysterectomy is one of the most common surgeries performed in women. Minimally invasive methods are on the rise globally as they have been shown to decrease surgical morbidity compared with abdominal hysterectomy. Hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) is the latest innovation. It combines the vaginal approach and endoscopy via the vagina. Large pragmatic randomised controlled trials (RCTs) are lacking comparing outcomes after vNOTES, vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH).

METHODS

Multicentre pragmatic RCT aiming to recruit 1000 women aged 18-75 years undergoing hysterectomy for benign disease. The RCT includes two identical substudies (groups A and B). If VH is considered safe and feasible, the patient will be randomised within group A (VH vs vNOTES). If VH is not considered safe or feasible, patients will be randomised within group B (LH vs vNOTES).

ANALYSIS

Primary outcome is the proportion of women leaving the hospital within 12 hours after surgery. Secondary outcomes are hospitalisation time, conversion rates, duration of the surgical procedure, intraoperative complications, postoperative complications and readmission.

ETHICS AND DISSEMINATION

The Ethical Board Committee at Imelda Hospital, Bonheiden, Belgium, has approved the research protocol 230704 (principal investigator). Before including patients, all centres will require local or national ethical approval. The results of the study will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05971875.

vNOTES retroperitoneal sentinel lymph node dissection for endometrial cancer staging: First multicenter, prospective case series

INTRODUCTION

The current standard treatment for endometrial cancer is a laparoscopic hysterectomy with adnexectomies and bilateral sentinel node resection. A retroperitoneal vNOTES sentinel node resection has several theoretical potential advantages. These include being less invasive, leaving no visible scars, operating without Trendelenburg, and therefore offering the anesthetic advantage of easier ventilation in obese patients and following the natural lymph node trajectory from caudally to cranially and therefore a lower risk of missing the sentinel node. The aim of this study is to determine the feasibility of a retroperitoneal vNOTES approach to sentinel lymph node dissection for staging of endometrial cancer.

MATERIAL AND METHODS

A prospective multicenter case series was performed in four hospitals. A total of 64 women with early-stage endometrial carcinoma suitable for surgical staging with sentinel lymph node removal were operated via a transvaginal retroperitoneal vNOTES approach. The paravesical space was entered through a vaginal incision after injecting the cervix with indocyanine green. A vNOTES port was placed into this space and insufflation of the retroperitoneum was performed. Sentinel lymph nodes were identified bilaterally using near-infrared light followed by endoscopic removal of these nodes.

RESULTS

A total of 64 women with early-stage endometrial cancer underwent sentinel lymph node removal by retroperitoneal vNOTES technique. All patients also underwent subsequent vNOTES hysterectomy and bilateral salpingo-oophorectomy. The median age was 69.5 years, median total operative time was 126 min and the median estimated blood loss was 80 mL. In 97% of the cases bilateral sentinel nodes could be identified. A total of 60 patients had negative sentinel nodes, three had isolated tumor cells and one had macroscopically positive sentinel nodes. No complications with sequel occurred.

CONCLUSIONS

This prospective multicenter case series demonstrates the feasibility of the vNOTES approach for identifying and removing sentinel lymph nodes in women with endometrial carcinoma successfully and safely. vNOTES allows sole transvaginal access with exposure of the entire retroperitoneal space, following the natural lymph trajectory caudally to cranially, and without the need for a Trendelenburg position.

Maternal origin matters: Country of birth as a risk factor for obstetric anal sphincter injuries

OBJECTIVE

Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long-term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS.

METHODS

A Swedish nationwide cohort study including singleton term vaginal births during 2005-2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub-analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC).

RESULTS

In all, 988 804 births were included. The rate of OASIS in Swedish-born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60-1.83), as did women born in Sub-Saharan Africa (aRR 1.60, 95% CI 1.49-1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56-0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60-3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92-0.98), but not significantly more protective among women with female genital mutilation.

CONCLUSIONS

Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub-Saharan Africa are at significantly increased risk as compared with Swedish-born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS.

vNOTES retroperitoneal transient uterine artery occlusion: a new approach to control bleeding during a high-risk evacuation of products of conception

OBJECTIVE

To describe a retroperitoneal transient occlusion of the uterine or internal iliac artery in conjunction with a high-risk evacuation of products of conception. The procedure was performed vaginally, minimally invasively, via vaginal natural orifice transluminal endoscopic surgery.

DESIGN

Description of the surgical technique using original video footage. This study was exempted from requiring hospital institutional review board approval.

SETTING

Teaching hospital.

PATIENT(S)

A 34-year-old woman (G8P3) with a medical history of 2 cesarean sections, 1 partial mole, and a missed abortion with 2.8 L of blood loss. The patient presented after 10 weeks of amenorrhea. Ultrasound revealed a large blood-filled niche in the cesarean section scar with a thin overlying myometrium. A partial mole was suspected as well as increased vascularization in the myometrium and enhanced myometrial vascularity with arterial flow velocities of 100 cm/s. A risk of heavy blood loss in conjunction with curettage was anticipated. The patient had a strong preference for a fertility-preserving treatment, and after informed consent, she opted for transient occlusion of the uterine arteries with subsequent suction evacuation of the molar pregnancy. The patient signed a consent form accepting the procedure. The patient included in this video provided consent for publication of the video and posting of the video online including social media, the journal website, and scientific literature websites. Institutional review board approval was not required in accordance with the IDEAL guidelines.

INTERVENTION(S)

A vaginal incision was made over the bladder, and the vaginal mucosa was dissected. The paravesical space was dissected over the arcus tendinous, and the pelvic retroperitoneal space was opened. A small (7 cm) GelPOINT V-Path (Applied Medical, Rancho Santa Margarita, California) was inserted into the obturator fossa and insufflated with 10 CO2 mm Hg. Standard laparoscopic instruments were used through the gel port. Under endoscopic view, dissection to the right obturator fossa and iliac vessels was made, and the internal iliac artery was identified. A removable clip was placed on the origin of the right uterine artery. The same procedure was performed on the left side where the internal iliac artery was clipped. Different vessels were clipped to demonstrate and investigate the feasibility of both approaches. Both vessels were equally accessible. Care should be taken not to injure the uterine vein at the time of clipping. Dilation and evacuation was performed under transanal ultrasound surveillance. When hemostatic control was assured, first, the right clip was removed from the iliac artery. Hemostatic control was ensured, and after 10 minutes, the second clip on the left iliac artery was removed. The GelPOINT was removed, and the vaginal incision was sutured. The patient bled in total 500 mL.

MAIN OUTCOME MEASURE(S)

Not applicable.

RESULT(S)

The patient recovered swiftly without complications. Pathology confirmed a partial molar pregnancy.

CONCLUSION(S)

Uterine or internal iliac artery ligation can be lifesaving in situations with massive bleeding from the uterus. Current minimally invasive approaches are laparoscopic vessel ligation and, more commonly, uterine artery embolization, which has unclear impact on fertility and has shown an increased risk of intrauterine growth restriction, miscarriage, and prematurity. As the patient was undergoing a vaginal evacuation of pregnancy, a vaginal and retroperitoneal approach of artery ligation was deemed least invasive. In patients with fertility-preserving wishes, care should to be taken to avoid as much trauma as possible to the endometrium. Optimized blood control, and a shorter duration of using a curette, may potentially reduce the risk of endometrial damage. We present a novel minimally invasive approach via vaginal natural orifice transluminal endoscopic surgery-retroperitoneal transient occlusion of the internal iliac or uterine artery. The whole procedure can be performed by the operating gynecologist, and the occlusion is transient and can be reversed in a stepwise controlled manner.

Acquired uterine arteriovenous malformation-Does it really exist? A case report

Acquired arteriovenous malformations (AVM) of the uterus can cause life-threatening vaginal bleeding and are associated with previous pregnancy, abortion or pelvic trauma. The pathophysiology is not well understood and the diagnosis is usually made by greyscale ultrasound often with nonspecific imaging findings, hence making it difficult to establish a correct diagnosis and therefore also the true incidence. However, case reports have previously described a connection between AVM formation and placental invasive disorders. In this report we demonstrate a case of a woman diagnosed with an AVM by ultrasound, presenting with menorrhagia after a termination of pregnancy, resulting in an emergency hysterectomy where subsequently a vascular malformation was found in conjunction with a remnant of a placenta increta and a placental site nodule. We hence suggest the hypothesis that these conditions are part of the same pathological process in the spectrum of abnormal invasive placental disorders, and that in the setting of previous trophoblastic processes, vascular malformations may mimic AVMs and ought not in fact to be considered as true AVMs.

Old meets new: vNOTES retroperitoneal promontory fixation in conjunction with the uterus preserving Manchester procedure✰,✰✰

INTRODUCTION AND HYPOTHESIS

The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.

[vNOTES hysterectomy - a new minimally invasive method for gynecologic surgery]

vNOTES hysterectomy is a scarless minimally invasive method with a vaginal approach to the abdominal cavity combined with endoscopic overview. Studies have shown that patients who underwent vNOTES hysterectomy had less pain and shorter hospital stay than after laparoscopic hysterectomy.

Manual Placenta Removal is Associated with Increased Postpartum Prescriptions of Antibiotics: a Retrospective Cohort Study of Data from the Anti-Infection Tool

Purpose

No consensus exists whether to administer prophylactic antibiotics in conjunction with manual placenta removal. This study aimed to investigate the postpartum risk of a new prescription of antibiotic treatment, a possible indirect variable for infection, after manual placenta removal.

Methods

Obstetric data were merged with data from the Anti-Infection Tool (Swedish antibiotic registry). All vaginal deliveries (n = 13 877) at Helsingborg Hospital, Helsingborg, Sweden, from January 1st, 2014 until June 13th, 2019 were included. Diagnosis codes for infection can be lacking, while the Anti-Infection Tool is complete as it is unavoidable in the computerized prescription system. Logistic regression analyses were performed. The risk of a prescription of antibiotics 24 h to 7 days postpartum was analyzed in the entire study population, and in a subgroup of women not having received any antibiotics 48 h prior to delivery until 24 h after delivery, referred to as "antibiotic-naïve."

Results

Manual placenta removal was associated with an increased risk of an antibiotic prescription, adjusted (a) OR = 2.9 (95%CI 1.9-4.3). In the antibiotic-naïve subgroup, manual placenta removal was associated with an increased risk of antibiotic prescription, in general, aOR = 2.2 (95%CI 1.2-4.0), endometritis-specific antibiotics, aOR = 2.7 (95%CI 1.5-4.9), and intravenous antibiotics, aOR = 4.0 (95%CI 2.0-7.9).

Conclusion

Manual placenta removal is associated with an increased risk of antibiotic treatment postpartum. An antibiotic-naïve population might benefit from prophylactic antibiotics to reduce the risk of infection, and prospective studies are needed.

Relation between perinatal outcome and gestational duration in term primiparous pregnancies stratified by body mass index

INTRODUCTION

There is growing evidence that induction of labor at 41 completed weeks improves neonatal outcome, at least among primiparous women. This study was performed to investigate whether maternal body mass index (BMI) should be considered when deciding on timing of intervention in term pregnancies.

MATERIAL AND METHODS

The study design was a historical cohort study using data from the Swedish Medical Birth Register, singletons in cephalic presentation with births 39+0 to 41+6 weeks, with available information on maternal BMI 2005-2017 (n = 352 567). Modified Poisson regression analyses were used to investigate the association between gestational duration and stillbirth or death before 45 postmenstrual weeks (primary outcome) and Apgar score <7 at 5 minutes (secondary outcome) by BMI, respectively. Adjustments were made for maternal age, smoking, country of birth and educational level.

RESULTS

The adjusted relative risk (ARR) of stillbirth or death before 45 weeks among infants born at 41+0 to 41+6 vs 40+0 to 40+6 weeks, was 1.26 with a 95% confidence interval (CI) of 1.07-1.48. Among women with BMI ≥30, the offspring mortality risk in pregnancies lasting 39+0 to 39+2 weeks was significantly above the corresponding risk among women of normal BMI who delivered at 41+0 to 41+2 weeks (ARR = 1.95; 95% CI 1.07-3.56) but no statistically significant heterogeneity was found regarding the magnitude of the association between gestational duration and offspring mortality. The ARR, for Apgar <7 at 5 minutes (41+0 to 41+6 vs 40+0 to 40+6 weeks, regardless of BMI), was 1.36 (95% CI 1.27-1.45). The risk for low Apgar score at 41+0 weeks was 1.5% among all children regardless of maternal BMI. Among children to women with BMI ≥30, this magnitude of risk was found already at 39+3 weeks.

CONCLUSIONS

In primiparous women with obesity the risk of stillbirth or death before 45 postmenstrual weeks were increased throughout all full-term gestational age categories, compared with women with overweight or normal BMI. Children to obese women had the same risk for Apgar scores <7 at 5 minutes compared with women overall at earlier gestational age. The results suggest that maternal BMI needs to be considered when discussing timing of elective induction in term healthy pregnancies of primiparous women.

Obstetric anal sphincter injuries-Maternal, fetal and sociodemographic risk factors: A retrospective register-based study

INTRODUCTION

Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potentially serious long-term consequences and large impact on quality of life. The aim was to determine risk and protective factors for OASIS.

MATERIAL AND METHODS

We performed a retrospective register-based observational study. A cohort of 988 988 singleton term deliveries 2005-2016 in Sweden were included. Data from the Swedish Medical Birth Registry and Statistics Sweden were extracted to identify cases of OASIS and maternal and fetal characteristics. Modified Poisson Regression analyses were performed to assess risk factors.

RESULTS

The rate of OASIS was 3.5% (n = 34 583). Primiparity (adjusted risk ratio [aRR] 3.13, 95% CI 3.05-3.21), vacuum extraction (aRR 2.79, 95% CI 2.73-2.86), forceps (aRR 4.27, 95% CI 3.86-4.72), and high birthweight (aRR 2.61, 95% CI 2.50-2.72) were associated with a significantly increased risk of OASIS. Increasing maternal age and decreasing maternal height also increased the risk of OASIS. Obesity increased the risk of OASIS (aRR 1.04, 95% CI 1.04-1.08), if fetal birthweight was not adjusted for. Smoking (aRR 0.74, 95% CI 0.70-0.79) and low maternal education (aRR 0.87, 95% CI 0.83-0.92) were associated with a decreased frequency of reported OASIS. Previous cesarean section increased the risk of OASIS (aRR 1.41, 95% CI 1.36-1.47).

CONCLUSIONS

Primiparity, instrumental delivery, and high birthweight significantly increased the risk of OASIS. Obesity, low height, increasing age, and previous cesarean section also increased the risk whereas smoking and low maternal educational level were associated with a lower OASIS rate.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Planned cesarean section versus planned vaginal delivery among women without formal medical indication for planned cesarean section: A retrospective cohort study of maternal short-term complications

INTRODUCTION

Rates of delivery by cesarean section have gradually risen in many parts of the world, and it is regarded as a safe surgical procedure with expanded indications. We assessed maternal complications within 6 weeks postpartum after planned cesarean section and after planned vaginal delivery among patients without medical indication for cesarean section.

MATERIAL AND METHODS

This was a retrospective cohort study based on Swedish national registers and included 714 326 deliveries from 2008 to 2017. The study group consisted of cephalic, singleton, term pregnancies and excluded those with previous cesarean or pregnancy conditions that would qualify for cesarean section. We compared the risks of short-term complications between planned cesarean section and planned vaginal delivery. We obtained adjusted risk ratios (ARRs) using modified Poisson regression models adjusting for maternal age, parity, body mass index, smoking, country of birth, and county.

RESULTS

The outcomes studied were infections and thromboembolism. In the planned cesarean section group (n = 22 855), 15% had a postpartum infection compared with 10% in the planned vaginal group (n = 691 471) (ARR 1.6; 95% confidence interval [CI] 1.5-1.6), and 0.08% vs. 0.05% had a postpartum pulmonary embolism (ARR 1.7; 95% CI 1.0-2.6). The obtained risk estimates corresponded to "number needed to harm" estimates of 17 and 3448, respectively. When dividing the infections into subgroups, the risk of endometritis (ARR 1.2; 95% CI 1.1-1.3), wound infection (ARR 2.7; 95% CI 2.4-3.0), urinary tract infection (ARR 1.5; 95% CI 1.3-1.7), and mastitis (ARR 2.0; 1.9-2.2) was higher after planned cesarean section.

CONCLUSIONS

Among patients without medical indication for planned cesarean section, the risks of short-term maternal complications were higher with planned cesarean section than with planned vaginal delivery.

Standardized 10-step approach for successfully performing a hysterectomy via vaginal natural orifice transluminal endoscopic surgery

Vaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel technique for minimally invasive gynecological surgery. Adequate training and standardization are key elements to patient safety and quality of care. Based on consensus statements and expert opinion; we report a step-by-step guidance for hysterectomy via natural orifice transluminal endoscopy. A detailed description is presented of pre- and postoperative care, and the instruments and equipment used, and surgical steps are illustrated by photographic images. This report can guide surgeons in their training to perform a hysterectomy via NOTES.

Accelerated cortical thinning and volume reduction over time in young people at high genetic risk for bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a familial psychiatric disorder associated with frontotemporal and subcortical brain abnormalities. It is unclear whether such abnormalities are present in relatives without BD, and little is known about structural brain trajectories in those at risk.

METHOD

Neuroimaging was conducted at baseline and at 2-year follow-up interval in 90 high-risk individuals with a first-degree BD relative (HR), and 56 participants with no family history of mental illness who could have non-BD diagnoses. All 146 subjects were aged 12-30 years at baseline. We examined longitudinal change in gray and white matter volume, cortical thickness, and surface area in the frontotemporal cortex and subcortical regions.

RESULTS

Compared to controls, HR participants showed accelerated cortical thinning and volume reduction in right lateralised frontal regions, including the inferior frontal gyrus, lateral orbitofrontal cortex, frontal pole and rostral middle frontal gyrus. Independent of time, the HR group had greater cortical thickness in the left caudal anterior cingulate cortex, larger volume in the right medial orbitofrontal cortex and greater area of right accumbens, compared to controls. This pattern was evident even in those without the new onset of psychopathology during the inter-scan interval.

CONCLUSIONS

This study suggests that differences previously observed in BD are developing prior to the onset of the disorder. The pattern of pathological acceleration of cortical thinning is likely consistent with a disturbance of molecular mechanisms responsible for normal cortical thinning. We also demonstrate that neuroanatomical differences in HR individuals may be progressive in some regions and stable in others.

Stillbirth or neonatal death before 45 post-menstrual weeks in relation to gestational duration in pregnancies at 39 weeks of gestation or beyond: the impact of parity and body mass index. A national cohort study

OBJECTIVE

To investigate the risk of stillbirth or neonatal death before 45 post-menstrual weeks in relation to gestational duration, stratified by body mass index (BMI) and parity.

DESIGN

Retrospective study.

SETTING

Data from the Swedish Medical Birth Register.

POPULATION

Singleton, cephalic births at between 39⁺⁰ and 42⁺²  weeks of gestation, 2005-2016 (n = 892 339).

METHODS

Relative risk ratios for mortality in relation to gestational duration were stratified by parity and BMI, and were adjusted for maternal age, smoking, country of birth and educational level.

MAIN OUTCOME MEASURES

Primary outcome: stillbirth or neonatal death before 45 post-menstrual weeks. Secondary outcome: stillbirth.

RESULTS

Among children of primiparous women, children born at 41⁺³  weeks of gestation, or later, were at increased risk of stillbirth or neonatal death before 45 post-menstrual weeks compared with children born between 39⁺⁰ and 40⁺²  weeks of gestation (aRR 1.29, 95% CI 1.10-1.52). For primiparous women with BMIs of <25, 25-29.9 and ≥ 30 kg/m² , the corresponding aRRs were: 1.04 (95% CI 0.81-1.34), 1.25 (95% CI 0.94-1.66) and 1.52 (95% CI 1.10-2.10), respectively. No significant increase in risk with gestational age was detected for multiparous women, regardless of BMI class. Among primipara, the risk of stillbirth increased with gestational duration in all BMI classes, with the highest risk increase for BMI ≥ 30 kg/m² , from 0.8/1000 at 40⁺³ -40⁺⁶  weeks of gestation to 4.0/1000 at 42⁺⁰ -42⁺²  weeks of gestation.

CONCLUSIONS

At 41⁺³ -42⁺²  weeks of gestation, pregnancy duration was associated with an increased risk for stillbirth or neonatal death before 45 post-menstrual weeks among primiparous women, especially among women who were obese. For multiparous women, no significant association between gestational duration and mortality was found.

TWEETABLE ABSTRACT

In term pregnancies the risk for stillbirth and neonatal death is affected by gestational age, parity and BMI.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Retrospective study of maternal and neonatal outcomes after induction compared to spontaneous start of labour in women with one previous birth in uncomplicated pregnancies ≥ 41+3

OBJECTIVES

To study the association between induction and outcome among two-parous women in uncomplicated pregnancies ≥ 41+3, stratified by first labour delivery mode and conditions present at first delivery.

METHODS

The Swedish Medical Birth Register was used to identify 58,964 uncomplicated singleton pregnancies among women with one previous birth between 1998 and 2014. Women with any registered pregnancy complications were excluded to minimise the risk for indication bias. The outcomes considered were emergency caesarean section (CS), and poor neonatal outcome (Apgar score <7 at 5 min, neonatal death, or meconium aspiration).

RESULTS

Women who were induced at their second labour had higher emergency CS rates compared to women in spontaneously started deliveries (adjusted risk ratio, ARR: 2.11; 95% CI: 2.00-2.23). Low Apgar score was more common after induction compared to spontaneously started labours (1.0 vs. 0.7%) (ARR: 1.44; 95% CI: 1.18-1.77). Increased CS rates were also found when comparing induction at 41 + 3 to 41 + 6 weeks to labour at 42 weeks or more, regardless of labour start (ARR 1.39; 95% CI: 1.26-1.52).

CONCLUSIONS

We found an increased risk of CS and poor neonatal outcome after second labour induction in prolonged pregnancies. The second labour vaginal success rate after induction was highly dependent, on first labour delivery mode, but also on diagnoses and conditions present at the first delivery.

Comparison of transperineal and endoanal ultrasound in detecting residual obstetric anal sphincter injury

INTRODUCTION

Endoanal ultrasound is considered the gold standard when assessing the obstetric anal sphincter complex. Due to its relative intrusiveness and economic cost, other ultrasound modalities are on the rise, such as transperineal ultrasound with a convex probe. The aim of our study was to evaluate the agreement between endoanal ultrasound scores (EAUS score) and transperineal ultrasound scores (TPUS score) in assessing residual obstetric anal sphincter defects.

MATERIAL AND METHODS

Fifty-nine women were examined 6 months after primary suturing of obstetric anal sphincter injury with two ultrasound modalities. A standardized scoring system analyzing the length, depth and radial extent of both the external (EAS) and internal (IAS) sphincter was used. Wexner fecal incontinence score was used to assess the patients' symptoms.

RESULTS

Transperineal ultrasound scores score showed a strong significant correlation with EAUS score during both pelvic floor relaxation and contraction: Spearman's rho [r_s ] = 0.74, P < 0.001, and r_s  = 0.77, P < 0.001, respectively. For both EAS and IAS, significant correlations were found for all parameters, that is, length, depth and angle between both EAUS and TPUS. A statistically significant correlation was found between EAUS score and Wexner score (r_s  = 0.36, P = 0.005). A significant correlation between the EAS-EAUS score (r_s  = 0.36, P = 0.005) and Wexner score was found, but no significance was found between IAS-EAUS score and Wexner score (r_s  = 0.22, P = 0.097). Significant correlations were found for Wexner score and TPUS score in resting state (r_s  = 0.36, P = 0.01) and contracting state (r_s  = 0.28, P < 0.05), and between Wexner score and EAS-TPUS score in resting state (r_s  = 0.32, P = 0.02).

CONCLUSIONS

The results indicated a strong agreement between endoanal and transperineal ultrasound in assessing residual obstetric anal sphincter defects 6 months after primary suturing. Furthermore, a weak significant correlation was found between the ultrasound scores and the patients' Wexner fecal incontinence score.

Improved neonatal outcome after active management of prolonged pregnancies beyond 41+2 weeks in nulliparous, but not among multiparous women

INTRODUCTION

Prolonged pregnancies are associated with adverse maternal and fetal outcome. In Sweden, no national guidelines exist for when to induce prolonged pregnancies.

MATERIAL AND METHODS

Singleton cephalic prolonged pregnancies (defined as ≥ 41⁺³ gestational weeks) during 2001-2013 (n = 199 770) were identified using the Swedish Medical Birth Register. The maternity units were divided into three groups (tertiles) based on the proportion of pregnancies ≥ 42⁺³ gestational weeks among all pregnancies ≥ 41⁺³  weeks. The pregnancy outcome among women delivered at the units with the most expectant management of prolonged pregnancies (> 17.6% proceeding to 42⁺³  weeks), was compared with that among women delivered at units with the most active management (< 12.6% proceeding to 42⁺³  weeks). Odds ratios (OR) were calculated using simple and multiple logistic regression. Adjustments were made for year of delivery, hospital level, maternal age, body mass index, and smoking.

RESULTS

Among primiparas, an increased risk of Apgar score < 7 at 5 minutes [odds ratio (OR) 1.27, 95% CI 1.16-1.41] and meconium aspiration (OR 1.49, 95% CI 1.14-1.95) was found after birth at most expectant units compared with most active units, but among multiparas, no such associations were detected. A decreased rate of cesarean section was found for both primiparas (OR 0.83, 95% CI 0.80-0.86) and multiparas (OR 0.82, 95% CI 0.77-0.86) at units with expectant vs. active management. No association between perinatal death and delivery-unit specific management of prolonged pregnancies was detected.

CONCLUSIONS

Offspring to primiparas might gain from a more active management of prolonged pregnancies, whereas no such improvement of neonatal outcome among multiparous women was detected.

Laparoscopic and open inguinal hernia repair: Patient reported outcomes in the elderly from a single centre - A prospective cohort study

Background

With those over 65 making up over 16% of the UK's population, surgeons are counselling increasing numbers of elderly patients for hernia repair. Data is currently lacking comparing different repair methods of inguinal hernias in the elderly population with regards to patient reported outcomes.

Aim

To compare open and laparoscopic hernia repair in patients >65 years old and those <65 years old with respect to patient reported outcomes.

Method

As part of a quality assurance process patients receive a telephone consultation day 2 post procedure. This includes an optional survey with questions to quantify pain, general feeling, nausea, dizziness, drowsiness, satisfaction and vomiting since the operation. Patients were then classified into age ≥ 65 years or <65 years and subclassified into totally extraperitoneal (TEP) or open inguinal hernia repair (IHR).

Results

Data is presented from patients treated between January 2009 and August 2016, totalling those included 1167 of 2522 (55.5%). Only five patients (4.42%) reported moderate pain; in the >65 TEP group this was significantly lower (10.2% open IHR <65; 6.7% TEP <65; 12.8% open IHR >65). Patient satisfaction with the surgery was satisfied or very satisfied in all patients in all groups.

Conclusion

Time off work is not an absolute appropriate measure of return to premorbid status with respect to the elderly as a substantial number of >65 year olds have retired. We therefore present this interesting insight into patient perceptions following hernia repair by age group. Overall patients over 65 can expect the same high levels of satisfaction and low levels of pain following either technique for inguinal hernia repair as younger patients.

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Time off work is not an appropriate measure of laparoscopic hernia repair in the over 65 year old population as the majority of this cohort is retired.

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Dizziness and drowsiness appeared to be no more prevalent in the over 65 year age group.

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Patient satisfaction with the surgery was satisfied or very satisfied in all patients in all groups.

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Overall a patient of any age can expect the same high levels of satisfaction and low levels of pain with either technique.

Effect of forage and retail packaging types on meat quality of long-term chilled lamb loins

The objectives of this study were to determine the effects of different forage regimes and modified atmosphere packaging (MAP) systems [high oxygen (HiOx-MAP): 80% O2 and 20% CO2; and CO2-MAP: 20% CO2 and 80% N2] on color and lipid oxidation stability and sensory attributes of long-term chilled lamb loins during retail display. Lambs (n = 124) were randomly assigned to several pasture-feeding regimes for 12 wk before slaughter. Some had ryegrass (n = 18), lucerne (n = 18), chicory (n = 19), plantain (n = 16), or red clover (Clover 12; n = 17) for all 12 wk. Some were assigned a regime of red clover for 11 wk and pasture for 1 wk (Clover 11; n = 18), with others on red clover for 9 wk and pasture for 3 wk (Clover 9; n = 18). After the lambs were slaughtered, the paired loins (M. longissimus dorsi) were excised at 24 h postmortem, vacuum-packed and stored at -1.5 °C for 9 wk. Cuts were then made from each loin and randomly allocated to either HiOx-MAP or CO2-MAP, and displayed for 7 d at 4 °C under light. Chemical attributes including lipid oxidation, surface color-reversing ability, oxygen consumption, and meat quality attributes (color stability and sensory characteristics) were determined. Among the different forage types, the loins from lambs finished on ryegrass appeared to have greater color stability and less lipid oxidation than the loins from lambs finished on other forage types (P < 0.05). On the other hand, the loins from lambs finished on lucerne had the least color and lipid oxidation stabilities and least color-reversing ability (P < 0.05). The loins from lambs finished on chicory had higher aroma and flavor scores than other pasture types in general (P < 0.05). HiOx-MAP negatively influenced meat quality attributes of lamb loins during display, as substantial increases in surface discoloration and lipid oxidation were observed, along with significant decreases in aroma and flavor during retail display compared with the loins in CO2-MAP. These results suggest that different forage types and packaging conditions could result in substantial impacts on meat quality attributes of long-term chilled lamb loins by affecting oxidation stability. Furthermore, the present study suggests that CO2-MAP could provide beneficial effects on the eating quality of long-term chilled lamb loins by suppressing oxidation-related defects during display without compromising the ability of blooming for meat display.

Mismatch Negativity and P300 to Behaviorally Perceptible and Imperceptible Frequency and Intensity Contrasts

Mismatch negativity and the P300 have been investigated as electrophysiological indices of behavioral auditory discrimination of duration. Using an oddball paradigm, responses were evoked to stimuli that had been behaviorally demonstrated to be either perceptible or imperceptible. The results indicated P300 events were present with the perceptible contrast but absent for the imperceptible contrast with all participants, while mismatch negativities were present in approximately 80 and 20% of participants to the perceptible and imperceptible contrasts, respectively. The present study extended the findings by applying the same paradigm to the discrimination of spectral and amplitude contrasts. 10 young adults with normal hearing were participants. Assuming that auditory assessment should involve representation and processing in all acoustic domains (i.e., temporal/duration, spectral/frequency and amplitude/intensity), the effects seen with temporal contrasts were predicted to be similar for spectral and amplitude contrasts. The findings generally illustrated that the P300 was more accurate than the mismatch negativity in reflecting behavioral discrimination. Together, these studies challenge the use of mismatch negativity as an electrophysiological correlate for behavioral discrimination of auditory perceptible contrasts.

Ductus venosus blood flow velocity waveform in diabetic pregnancies

OBJECTIVE

Maternal diabetes during pregnancy is associated with congenital cardiac malformations and hypertrophic cardiomyopathy. Blood flow in the ductus venosus (DV) has been postulated to reflect cardiac function. The aim of our study was to investigate if diabetic pregnancies exhibit abnormal DV hemodynamics, hence indicating changes in fetal cardiac function.

METHODS

The pulsatility index of the DV (DV-PI) was analyzed retrospectively in 142 diabetic patients and compared to previously published DV-PI reference values from a non-diabetic low-risk population. DV values were then correlated with maternal glycosylated hemoglobin (HbA1c).

RESULTS

DV-PI was significantly higher in pregnancies complicated by either pre-existing insulin-dependent (DM) or gestational diabetes when compared with normal reference values. Increased DV-PI values were still evident in both diabetic groups when neonates that were small-for-gestational age and neonates with pathological umbilical blood flow pattern were excluded from the analysis. In DM pregnancies a statistically significant correlation was found between DV-PI and maternal HbA1c.

CONCLUSION

Diabetic pregnancies exhibit increased DV-PI values when compared to a normal low-risk pregnant population, possibly indicating a fetal cardiac effect.

Fetal electrocardiographic monitoring during labor in relation to cord blood levels of the brain-injury marker protein S-100

BACKGROUND

Cord artery protein S-100 levels at birth are potential markers of brain damage after asphyxia. Our aim was to investigate if S-100 levels were elevated in neonates with indirect signs of asphyxia during birth. S-100 levels in cord blood were studied in relation to cardiotocography (CTG) and fetal electrocardiography (FECG) changes during birth and to acidemia in umbilical blood.

MATERIAL AND METHODS

This case-control study was performed in parallel to a large randomized controlled trial (RCT) studying FECG at birth. Protein S-100 samples were collected from 103 neonates at birth and related to the CTG and ECG changes during labor and to pH in umbilical blood.

RESULTS

Protein S-100 was significantly higher in neonates with umbilical artery blood pH<or=7.05, compared to neonates with pH>7.05. Furthermore, neonates with preterminal CTG patterns showed increased S-100 levels compared to neonates with normal CTG. Neonates having significant CTG and ECG changes, leading to intervention according to clinical guidelines, showed significantly higher S-100 levels compared to neonates without such indication of intervention.

CONCLUSION

A relation exists between S-100 in umbilical blood at birth, acidosis and pathological patterns in CTG and FECG during labor.

Characterization of the antimicrobial peptide attacin loci from Glossina morsitans

The antimicrobial peptide Attacin is an immune effector molecule that can inhibit the growth of gram-negative bacteria. In Glossina morsitans morsitans, which serves as the sole vectors of African trypanosomes, Attacins also play a role in trypanosome resistance, and in maintaining parasite numbers at homeostatic levels in infected individuals. We characterized the attacin encoding loci from a Bacterial Artificial Chromosome (BAC) library. The attacin genes are organized into three clusters. Cluster 1 contains two attacin (attA) genes located in head-to-head orientation, cluster 2 contains two closely related genes (attA and attB) located in a similar transcriptional orientation, and cluster 3 contains a single attacin gene (attD). Coding and transcription regulatory sequences of attA and attB are nearly identical, but differ significantly from attD. Putative AttA and AttB have signal peptide sequences, but lack the pro domain typically present in insect Attacins. Putative AttD lacks both domains. Analysis of attacin cDNA sequences shows polymorphisms that could arise either from allelic variations or from the presence of additional attacin genomic loci. Real time-PCR analysis reveals that attA and attB expression is induced in the fat body of flies per os challenged with Escherichia coli and parasitized with trypanosomes. In the midgut, expression of these attacins is similarly induced following microbial challenge, but reduced in response to parasite infections. Transcription of AttD is significantly less relative to the other two genes, and is preferentially induced in the fat body of parasitized flies. These results indicate that the different attacin genes may be differentially regulated.

Unraveling the complex nature of prostate cancer stem cells

The identification of distinct prostate cancer stem cell biomarkers is necessary as researchers attempt to isolate, characterize, and therapeutically target these tumor initiating cells. However, in reading the current literature it is frequently difficult to discern which biomarkers and cellular characteristics identify prostate cancer stem cells as opposed to the general population of prostate cancer cells or normal prostate stem cells. Within this review, we address this issue by dissecting out the cell surface markers, adhesion and cytoskeletal proteins, signaling pathways, epigenetic modifications, and the effects of androgens that are specific to and help to define the prostate cancer stem cell.

Rhabdomyosarcoma

Rhabdomyosarcoma, the most common soft tissue sarcoma of children, carried a 10-15% survival rate in the late 1960s. Since then, better understanding of biology and pathology of the tumor and the judicious use of chemotherapy and radiation has improved the prognosis drastically. In addition instead of extirpative surgery, organ salvage is now feasible in many of these children. In this article the authors review current information regarding pathology, diagnosis and treatment of rhabdomyosarcoma.

Continent catheterizable urinary conduit constructed from defunctionalized colon

The authors describe a technique for construction of a continent catheterizable stoma from distal defunctionalized colon in a patient with imperforate anus, urethral atresia, and sacral agenesis.

Interactive effects of low-pass filtering and masking noise on word recognition

A word recognition in noise paradigm was employed to examine temporal resolution in individuals with simulated hearing loss. Word recognition scores were obtained for low-pass filtered speech (i.e., cutoff frequencies of 1000,1250, and 1500 Hz) presented in continuous and interrupted noise at signal-to-noise ratios (SNRs) of -10, 0, and 10 dB. Performance improved with increasing SNR and low-pass frequency filter settings. Generally, word recognition performance was better in the interrupted noise condition than the continuous noise condition. This effect was greatest in the -10 dB SNR condition. Since the continuous/interrupted performance difference steadily declined as a function of low-pass filter cutoff frequency, these findings suggest that one factor leading to poorer speech recognition in individuals with high-frequency hearing impairment may be their dependence on low-frequency hearing channels that are inherently poorer than high-frequency channels for temporal resolution.

Possible neuronal refractory or recovery artifacts associated with recording the mismatch negativity response

The mismatch negativity (MMN) is an event-related potential that involves a negative voltage shift of baseline electroencephalographic (EEG) activity in the approximate latency window of the N1 and P2 cortical potentials in response to new or novel sounds. The MMN is present at birth and has been hypothesized to serve as an automatic preconscious detector of changes in the auditory environment. Research paradigms used to extract the MMN response from EEG activity have a potential problem related to neuronal refractoriness or recovery. Both N1 and P2 are known to increase in amplitude with longer interstimulus intervals (ISIs). The MMN extraction procedures involve mathematical subtraction of waveforms elicited by standard sounds (with short ISIs) from those recorded to rare deviant sounds (with longer ISIs). Any ISI-dependent amplitude changes in N1 and/or P2 could therefore alter the morphology of the resulting difference wave and lead to misinterpretation of the nature of the underlying MMN generators. We tested 12 young females and found that the MMN can be influenced by ISI-dependent refractory effects that may modify the waveform morphology. This has important clinical implications since the MMN is being investigated as an assessment tool.

Producing the vowel/a/ prior to speaking inhibits stuttering in adults in the English language

This study investigated the effects of producing and listening to the vowel /a/ on the frequency of overt stuttering moments in eight people who stuttered. Stuttering frequency counts were made for the speech produced in the control condition, and after each of these four experimental conditions: (a) producing a vowel /a/ for 4 s; (b) producing a vowel /a/ for 4 s and waiting for 4 s; (c) listening to a recording of the vowel /a/ for 4 s; and (d) listening to a recording of the vowel /a/ for 4 s and waiting for 4 s. A significant reduction in the stuttering frequency was only observed following production of the vowel /a/ without a 4 s delay (P=0.02), suggesting that the vowel production prior to speech, serves as a temporary fluency enhancer. Its similarity to the occurrence of overt stuttering moments (e.g. discrete part-word repetitions and prolongation's) and its relationship to the fundamental nature of the pathology are discussed.

Effects of age, gender, bolus volume, and trial on swallowing apnea duration and swallow/respiratory phase relationships of normal adults

The effects of age, gender, bolus volume, and trial on swallowing apnea duration (SAD) and swallow/respiratory phase relationships were examined. Sixty adults, composed of ten males and ten females in each of three age groups (i.e., 20-39, 40-59, and 60-83 years), participated. SAD was assessed via nasal airflow during saliva swallows and 10-, 15-, 20-, 25-mL bolus volumes across three trials. Results revealed SAD is consistent across trial (p > 0.05). Significant main effects of age, gender, and bolus volume were found (p < 0.05), i.e., elderly adults had longer SAD than young and middle-aged adults; women had longer SAD than men; and SAD increased as bolus volume increased. With respect to saliva swallows, a significant interaction of age by gender was found (p < 0.05), i.e., males exhibited a decrease in SAD with increasing age while females exhibited an increase in SAD with increasing age. Concerning swallow/respiratory phase relationships, the pattern of exhale-swallow-exhale was evident during 62% of participants' swallows. Furthermore, age, gender, or bolus volume did not predict the pattern of exhale-swallow-exhale (p > 0.05).

Effect of age, gender, and repeated measures on intraoral air pressure in normal adults

The effect of age, gender, and repeated measures on intraoral air pressure (P0) was examined. Sixty adults comprised of 10 males and 10 females in each of three age groups (i.e., 20-39, 40-59, and 60-83 years) participated. P0 was assessed during voiceless stop plosive /p/ productions in repeated vowel/consonant syllables. The three medial plosives of a seven-syllable train were averaged to comprise a token. Five tokens were obtained and averaged for each of three trials. Thus each participant contributed 105 syllables and a subsequent three P0s for analyses. There was no statistically significant difference in P0 as a function of age or gender (P > 0.05). These findings support the conception that P0 remains stable throughout adulthood and is not dependent on gender. Differences in repeated measures of P0 attained statistical significance (P = 0.03), however the mean differences between trials (0.23 cm H20) were negligible and deemed to be clinically insignificant. Thus, across a short sampling session, P0 is a relatively stable measurement and does not change as a function of age or gender.

Transmission loss of sound into incubators: implications for voice perception by infants

OBJECTIVE

To assess the transmission of sound into incubators as a function of talker position (i.e., standing or sitting), incubator port position (i.e., opened or closed), and center frequency (i.e., 125 to 10,000 Hz in one-third octave steps). The second objective was to estimate the audibility of the human voice inside the incubator.

STUDY DESIGN

L(eq) measures of signal transmission loss and motor noise were obtained from two incubators.

RESULTS

In general, signal transmission loss was greater for the standing-talker position, with front portholes closed, and for high-frequency spectra. Motor noise was greater with both front portholes closed and for lower-frequency spectra. The greatest signal delivery to an infant would be obtained when the speaker is sitting using a raised vocal effort while the incubator ports are opened.

CONCLUSION

Measured signal transmission loss and motor noise characteristics of two incubators suggest that only mid-frequency speech spectra would be audible to infants and only at a speech-to-noise ratio of approximately 5 to 10 dB with a raised vocal effort.

Gender effects in auditory brainstem responses to air- and bone-conducted clicks in neonates

Examinations of gender differences in auditory brainstem response (ABR) wave V latencies and thresholds to air- and bone-conducted clicks were undertaken with neonates. Two hundred and two full-term neonates participated (i.e., 103 males and 99 females). Wave V latency measures for air- and bone-conducted click stimuli of 30, 45, and 60 dB nHL and 15 and 30 dB nHL, respectively, and thresholds to air- and bone-conducted clicks were determined. Female newborns displayed statistically significant shorter wave V latencies than male newborns for air-conducted click stimuli (i.e., approximately 0.2-0.3 ms; P=.0016). There were no significant gender differences in wave V latencies to bone-conducted click stimuli (P=.11). With respect to ABR thresholds, no statistically significant differences were observed for either air-conducted clicks (P=.054) or bone-conducted clicks (P=.18).

EDUCATIONAL OBJECTIVES

As a result of this activity, the participant will be able to (1) describe gender differences in ABR wave V latencies and thresholds to air- and bone-conducted clicks with neonates and (2) summarize possible explanations for observed gender differences in ABR wave V latencies and thresholds to air- and bone-conducted clicks with neonates.

Effects of exercise and noise on auditory thresholds and distortion-product otoacoustic emissions

Differences in auditory thresholds and distortion-product otoacoustic emission (DPOAE) levels were investigated as a function of gender, ear, frequency, and experimental condition: quiet sedentary activity, exercise, noise, and exercise and noise combined. In general, participants displayed significant elevations in auditory thresholds of approximately 6 to 13 dB following the two conditions employing noise exposure. There were no significant differences in either auditory threshold differences before and following the quiet and exercise conditions or between the noise-alone and combined exercise and noise conditions. Participants also displayed significant reductions in DPOAE levels of approximately 6 to 7 dB following the two conditions employing noise exposure. The findings also showed no gender or ear effects on auditory threshold or DPOAE level differences. Further, there was no evidence of a synergistic combination of exercise and noise on auditory function as revealed by changes in hearing threshold or DPOAE levels.

An investigation of maternal stress after neonatal hearing screening

An investigation was undertaken to determine whether mothers whose infants failed a newborn hearing screening (MWIF) had significantly more stress and were consequently at risk for dysfunctional attachment than those mothers whose infants passed a newborn hearing screening (MWIP). The Parenting Stress Index (PSI; Abidin, 1995), a screening and diagnostic assessment questionnaire designed to measure the relative magnitude of stress in a parent-child dyad, was used. Twenty MWIP and 20 MWIF participated. The PSI was administered through a telephone interview approximately 1 month after participants' discharge while their infants were between their fourth and fifth week of life. In the case of MWIF, the interview occurred before their infant's hearing retest. No significant differences in Total Stress, Life Stress, Child Domain, and Parent Domain subscale raw scores of the PSI were found between MWIP and MWIF (p > .05). An examination of the individual PSI profiles of all participants for "high" and "low" normative percentile scores (i.e., percentile scores > or = 90th percentile and percentile scores < or = 0 percentile for the former and latter, respectively) revealed that the incidence of high scale/subscale percentile scores was essentially equivalent between groups. MWIP, however, displayed lower scale/subscale percentile scores. The results of the study suggest that those mothers whose infants receive a refer outcome after a newborn hearing screening demonstrate equivalent stress levels as those mothers whose infants received a pass.

Stutter-free and stutter-filled speech signals and their role in stuttering amelioration for English speaking adults

This study examined the power of an exogenously generated stuttered speech signal on stuttering frequency when compared to an exogenously generated normal speech signal. In addition, we examined the specific components of the second speech signal, which might be responsible for the inducement of fluency in people who stutter. Eight males and two females who stuttered participated in this study. Experiment I involved meaningful speech: normal continuous speech, normal interrupted speech, stuttered continuous speech, and stuttered interrupted speech, whereas Experiment II involved vowels and consonants: /a/, /a-i-u/, /s/, /s-sh-f/. The results indicated that stuttered and normal speech signals were equally effective in reducing stuttering frequency. Further, the vowels were more powerful than consonants in inducing fluency for people who stutter. It is suggested that acoustic manifestations of stuttering, rather than a problem, may be a natural compensatory mechanism to bypass or inhibit the 'involuntary block' at the neural level.

Evaluation of a direct doctor-patient telephone advice line in general practice

A general practitioner-staffed direct access telephone advice line was made available for 30 minutes every morning at an inner-London practice to advise patients with urgent problems. Users valued the service, but the impact on surgery consultations was too small for this to be advocated as an alternative to emergency consultations.