Episiotomy: history, present and future - a review

Childbirth has always carried traumatic stress to the woman's body. To deliver with less perineal trauma, obstetricians have used episiotomies. Episiotomy is still a common practice despite the controversy regarding its use. Weighing the risks and benefits, the scientific literature supports its selective use. With the worldwide trend to reduce the rate of episiotomy, several techniques have been proposed to achieve that. However, further research is still needed to prove their efficacy. This review will shed light on the historical background of episiotomy, its different techniques, indications, and the future of its practice.

A Randomized Parallel Study to Assess the Effect of Three Tongue Cleaning Modalities on Oral Malodor

OBJECTIVES

The objective of this study was to compare the effects of three tongue hygiene regimens on oral malodor.

METHODS

This was a single-center, randomized, parallel design study with three treatment groups. Subjects were randomly assigned to perform tongue hygiene with either the Philips Sonicare TongueCare+ BreathRx regimen (STC), Listerine Cool Mint antiseptic rinse (LCM), or tongue brushing with an ADA reference manual toothbrush (MTB). Tooth brushing was standardized for all subjects during the study period, and no other oral or breath hygiene measures were allowed. Eligible subjects met the following criteria: aged 18-70 years, in good general and oral health, non-smoker, with an organoleptic score between 2.7 and 4.5 following a 12-18 hour oral hygiene abstention period. Subjects who had oral appliances or who had periodontal disease or excessive recession were not eligible. The primary endpoint analysis was to evaluate oral malodor based on an organoleptic (OL) score. Additional surrogate measures for oral malodor included quantification of oral hydrogen sulfide (H2S) level and counts of oral bacteria in secondary analyses. At Day 1, all three malodor endpoints were assessed prior to product use, immediately after use, and four and eight hours after use. Subjects were then provided with instructions on product use at home. Subjects returned to the clinic on Day 8 and the assessments for malodor were repeated for each of the three endpoints, i.e., prior to in-clinic use of the products, immediately after use, and four and eight hours after use.

RESULTS

One hundred sixty-eight (168) subjects were randomized to three groups, with 56 per treatment group. Of these, 165 completed all study visits. Randomized subjects were comparable for baseline characteristics (OL score, age, race, and ethnicity). Overall, oral malodor based on the organoleptic score decreased for all treatment groups at all timepoints. For the primary endpoint, reduction of OL score eight hours following a single product use, the STC regimen reduced malodor per OL score by 46.67% (SE = 2.28%), the LCM value was 22.83% (SE = 2.29%), and MTB was 26.19% (SE = 2.29%). The pair-wise comparisons between STC and each of the treatment groups were statistically significant (p-values < 0.0001). Statistically significant differences were also observed between STC and both LCM and MTB groups in pair-wise comparisons at Day 8 (p-values < 0.0001).

CONCLUSIONS

Reductions in malodor were evident following a single use of each product, and also following a seven-day repeat use period. The STC regimen, however, was statistically significantly superior to both LCM and MTB at improving malodor eight hours following the first use. Statistically significant differences in OL scores were sustained between STC and LCM, and STC and MTB at each efficacy timepoint following the seven-day home use period.

A Comparison of the Effect of Two Power Toothbrushes on the Reduction of Gingival Inflammation and Supragingival Plaque

OBJECTIVES

To compare the effect of the Philips Sonicare DiamondClean Smart and Oral-B Genius 8000 powered toothbrushes on gingivitis, gingival bleeding, and supragingival plaque reduction following 42 days of home use.

METHODS

This was a randomized, parallel, examiner-blinded, prospective clinical trial with two treatment groups. Eligible participants were generally healthy volunteers who were manual toothbrush users, non-flossers, 18-65 years of age. The subject panel included non-smokers with = 50 sites of gingival bleeding according to the Gingival Bleeding Index (GBI), and a supragingival plaque score of = 1.8 per Modified Plaque Index (MPI) at 3-6 hours following last tooth brushing encounter. Eligible subjects were randomized to use either a Philips Sonicare DiamondClean Smart with Premium Plaque Control brush head (DCS) or an Oral-B Genius 8000 with FlossAction brush head (OBG) for home use. Each toothbrush was used twice daily for two minutes. All subjects used a standardized fluoride-containing dentifrice. All other oral hygiene measures were prohibited. Subjects returned at Day 14 for an interim compliance and safety assessment, and at Day 42 for the final safety and efficacy assessments.

RESULTS

Of 222 enrolled and eligible subjects, 219 completed (112 in the SDC group, 107 in the OBG group) the study. The least squares (LS) mean and 95% confidence interval (CI) estimates for gingivitis reduction and percent reduction per Modified Gingival Index (MGI) following 42 days of product home use were 1.38 (1.30, 1.46) and 51.32% (48.45%, 54.19%) for DCS, and 0.53 (0.45, 0.61) and 20.07% (17.14%, 23.00%) for OBG. The differences, expressed as either reduction or percent reduction, were statistically significant between the two groups, p < 0.001. Statistically significant differences were also observed between products at Day 42 for the gingival bleeding and supragingival plaque reduction endpoints, p < 0.001. There were two reported adverse events.

CONCLUSIONS

The Philips Sonicare DiamondClean Smart powered toothbrush reduced gingival inflammation, gingival bleeding, and supragingival plaque significantly more than the Oral-B Genius 8000 powered toothbrush following a 42-day home-use period. Both products were safe for use.

Patient choice compared with no choice of intrathecal morphine dose for caesarean analgesia: a randomized clinical trial

Background

The study aimed to determine whether a patient's choice for their intrathecal morphine (ITM) dose reflects their opioid requirements and pain after caesarean delivery and if giving women a choice of ITM dose would reduce opioid use and improve pain scores compared with women who did not have a choice.

Methods

A total of 120 women undergoing caesarean delivery with spinal anaesthesia were enrolled in this randomized, double-blind study. Patients were randomly assigned to a choice of 100 or 200 μg ITM or no choice. The study involved deception, such that all participants were still randomly assigned 100 or 200 μg ITM regardless of choice. Rescue opioid use over the 48-h study period was the primary outcome measure. Pain at rest and movement and side effect (pruritus, nausea, and vomiting) data were collected 3, 6, 12, 24, 36 and 48 h postoperatively. Data are presented as median [95% confidence interval (CI)].

Results

Women who requested the larger ITM dose required more supplemental opioid [median 0.8 (95% CI 0.4-1.3)] mg morphine equivalents at each assessment interval; P  < 0.001] and reported more pain with movement [median 1.2 (95% CI 0.5-1.9)] verbal numerical rating score of 0-10 points] than patients who requested the smaller ITM dose ( P  = 0.0008), regardless of the ITM dose given. There was no difference in opioid use whether the patient was offered a perceived choice or not.

Conclusions

Women who were given a choice and chose the larger ITM dose correctly anticipated a greater postoperative opioid requirement and more pain compared with women who chose the smaller dose. Simply being offered a choice did not impact opioid use or pain scores after caesarean delivery.

Trial Registration

ClinicalTrials.gov (NCT01425762).

Does anticholinergics drug burden relate to global neuro-disability outcome measures and length of hospital stay?

PRIMARY OBJECTIVE

To assess the relationship between disability, length of stay (LOS) and anticholinergic burden (ACB) with people following acquired brain or spinal cord injury.

RESEARCH DESIGN

A retrospective case note review assessed total rehabilitation unit admission.

METHODS AND PROCEDURES

Assessment of 52 consecutive patients with acquired brain/spinal injury and neuropathy in an in-patient neuro-rehabilitation unit of a UK university hospital. Data analysed included: Northwick Park Dependency Score (NPDS), Rehabilitation complexity Scale (RCS), Functional Independence Measure and Functional Assessment Measure FIM-FAM (UK version 2.2), LOS and ACB. Outcome was different in RCS, NPDS and FIM-FAM between admission and discharge.

MAIN OUTCOMES AND RESULTS

A positive change was reported in ACB results in a positive change in NPDS, with no significant effect on FIM-FAM, either Motor or Cognitive, or on the RCS. Change in ACB correlated to the length of hospital stay (regression correlation = -6.64; SE = 3.89). There was a significant harmful impact of increase in ACB score during hospital stay, from low to high ACB on NPDS (OR = 9.65; 95% CI = 1.36-68.64) and FIM-FAM Total scores (OR = 0.03; 95% CI = 0.002-0.35).

CONCLUSIONS

There was a statistically significant correlation of ACB and neuro-disability measures and LOS amongst this patient cohort.

Optimizing the high-resolution manometry (HRM) study protocol

BACKGROUND

Intolerance of the esophageal manometry catheter may prolong high-resolution manometry (HRM) studies and increase patient distress. We assessed the impact of obtaining the landmark phase at the end of the study when the patient has acclimatized to the HRM catheter.

METHODS

366 patients (mean age 55.4 ± 0.8 years, 62.0% female) undergoing esophageal HRM over a 1-year period were studied. The standard protocol consisted of the landmark phase, 10 5 mL water swallows 20-30 s apart, and multiple rapid swallows where 4-6 2 mL swallows were administered in rapid succession. The modified protocol consisted of the landmark phase at the end of the study after test swallows. Study duration, technical characteristics, indications, and motor findings were compared between standard and modified protocols.

KEY RESULTS

Of the 366 patients, 89.6% underwent the standard protocol (study duration 12.9 ± 0.3 min). In 10.4% with poor catheter tolerance undergoing the modified protocol, study duration was significantly longer (15.6 ± 1.0 min, p = 0.004) despite similar duration of study maneuvers. Only elevated upper esophageal sphincter basal pressures at the beginning of the study segregated modified protocol patients. The 95th percentile time to landmark phase in the standard protocol patients was 6.1 min; as many as 31.4% of modified protocol patients could not obtain their first study maneuver within this period (p = 0.0003). Interpretation was not impacted by shifting the landmark phase to the end of the study.

CONCLUSIONS & INFERENCES

Modification of the HRM study protocol with the landmark phase obtained at the end of the study optimizes study duration without compromising quality.

Esophageal motor disease and reflux patterns in patients with advanced pulmonary disease undergoing lung transplant evaluation

BACKGROUND

Advanced pulmonary disorders are linked to esophageal hypomotility and reflux disease. However, characterization of esophageal function using high resolution manometry (HRM) and ambulatory pH monitoring, segregation by pulmonary pathology, and comparison to traditional reflux disease are all limited in the literature.

METHODS

Over a 4 year period, 73 patients (55.2 ± 1.3 years, 44F) were identified who underwent esophageal function testing as part of lung transplant evaluation for advanced pulmonary disease (interstitial lung disease, ILD = 47, obstructive lung disease, OLD = 24, other = 2). Proportions of patients with motor dysfunction (≥ 80% failed sequences = severe hypomotility) and/or abnormal reflux parameters (acid exposure time, AET ≥ 4%) were determined, and compared to a cohort of 1081 patients (48.4 ± 0.4 years, 613F) referred for esophageal function testing prior to antireflux surgery (ARS).

KEY RESULTS

The proportion of esophageal body hypomotility was significantly higher within advanced pulmonary disease categories (35.6%), particularly ILD (44.7%), compared to ARS patients (12.1%, P < 0.0001). Abnormal AET was noted in 56.5%, and was similar between ILD and OLD, but less frequent than in the ARS group (P = 0.04). Post-transplant chronic rejection trended towards association with pretransplant elevated AET in OLD (P = 0.08) but not ILD. Mortality was not predicted by esophageal motor pattern or reflux evidence.

CONCLUSIONS & INFERENCES

Interstitial lung disease has a highly significant association with esophageal body hypomotility. Consequently, prevalence of abnormal esophageal acid exposure is high, but implications for post lung transplant chronic rejection remain unclear.

Factors influencing the results of surgery for hypospadias: experience at NICH

OBJECTIVE

To evaluate the factors that may influence the results of surgery after hypospadias repair at National Institute of Child Health, Karachi.

METHODS

It was a retrospective observational study. Files of all patients who had Hypospadias repair were retrieved and analysed with a view to identify the factors which may influence the results of surgery for Hypospadias. Patients with complete record available were included in the study, whereas those with incomplete data were excluded. For most patients who had penile or distal hypospadias TIP (Tubularised Incised Plate) urethroplasty was performed. Patients with severe chordee had Duckett Island flap urethroplasty as a two stage procedure. Patients having moderate chordee were subjected to the Mustardee Procedure. Some underwent MAGPI and Mathieu's repairs.

RESULTS

One hundred four patients were operated. Files of only 46 patients with a mean age of 4 years could be retrieved and these were included in the study. Twenty five patients had TIP urethroplasty, 5 had island flap urethroplasty, 2 had Mustardee repair, 6 had MAGPI, 5 had Mathew's repair and 3 had Byers Staged Urethroplasty. Over all incidence of fistula formation was 26%. The frequency of fistula formation was less with TIP urethroplasty (16%) compared to those who received no dartos pedicle flap. Mathieu's repair gave good results with 20% incidence of fistula formation. Highest numbers of complications (60%) were seen in patients who had Island flap urethroplasty for proximal hypospadias with chordee.

CONCLUSION

TIP urethroplasty is a safe and reliable method of hypospadias repair. The results of surgery can however be improved by using dartos pedicle flap to protect the repair, meticulous surgical techniques, use of monofilamentous absorbable suture material and soft waterproof dressing.

Neural correlates of artificial grammar learning

Artificial grammar learning (AGL) is a form of nondeclarative memory that involves the nonconscious acquisition of abstract rules. While data from amnesic patients indicate that AGL does not depend on the medial temporal lobe, the neural basis of this type of memory is unknown and was therefore examined using event-related fMRI. Prior to scanning, participants studied letter strings constructed according to an artificial grammar. Participants then made grammaticality judgments about novel grammatical and nongrammatical strings while fMRI data were collected. The participants successfully acquired knowledge of the grammar, as evidenced by correct identification of the grammatical letter strings (57.4% correct; SE 1.9). During grammaticality judgments, widespread increases in activity were observed throughout the occipital, posterior temporal, parietal, and prefrontal cortical areas, reflecting the cognitive demands of the task. More specific analyses contrasting grammatical and nongrammatical strings identified greater activity in left superior occipital cortex and the right fusiform gyrus for grammatical stimuli. Increased activity was also observed in the left superior occipital and left angular gyrus for correct responses compared to incorrect. Comparing activity during grammaticality judgments versus a matched recognition control task again identified greater activation in the left angular gyrus. The network of areas exhibiting increased activity for grammatical stimuli appears to have more in common with studies examining word-form processing or mental calculation than the fluency effects previously reported for nondeclarative memory tasks such as priming and visual categorization. These results suggest that a novel nondeclarative memory mechanism supporting AGL exists in the left superior occipital and inferior parietal cortex.

A shift in the phenotype of melan-A-specific CTL identifies melanoma patients with an active tumor-specific immune response

In a significant proportion of melanoma patients, CTL specific for the melan-A(26/7-35) epitope can be detected in peripheral blood using HLA-A2/peptide tetramers. However, the functional capacity of these CTL has been controversial, since although they prove to be effective killers after in vitro expansion, in some patients they have blunted activation responses ex vivo. We used phenotypic markers to characterize melan-A tetramer(+) cells in both normal individuals and melanoma patients, and correlated these markers with ex vivo assays of CTL function. Melanoma patients with detectable melan-A tetramer(+) cells in peripheral blood fell into two groups. Seven of thirteen patients had a CCR7(+) CD45R0(-) CD45RA(+) phenotype, the same as that found in some healthy controls, and this phenotype was associated with a lack of response to melan-A peptide ex vivo. In the remaining six patients, melan-A tetramer(+) cells were shifted toward a CCR7(-) CD45R0(+) CD45RA(-) phenotype, and responses to melan-A peptide could be readily demonstrated ex vivo. When lymph nodes infiltrated by melan-A-expressing melanoma cells were examined, a similar dichotomy emerged. These findings demonstrate that activation of melan-A-specific CTL occurs in only some patients with malignant melanoma, and that only patients with such active immune responses are capable of responding to Ag in ex vivo assays.

Gene delivery to the corneal endothelium

Gene transfer to the corneal endothelium has potential for modulating rejection of corneal grafts. It can also serve as a convenient and useful model for gene therapy of other organs. In this article we review the work carried out in our laboratory using both viral and nonviral vectors to obtain gene expression in the cornea.

Management of injuries to the anterior cruciate ligament: results of a survey of orthopaedic surgeons in Canada

OBJECTIVE

To identify the approaches to management of anterior cruciate ligament (ACL) injury by Canadian orthopedic surgeons.

METHODS

A questionnaire was mailed to 234 physicians randomly chosen from the Canadian Orthopaedic Association directory to obtain the following information: 1) how orthopaedic surgeons diagnose acute hemarthroses; 2) how patients in any of three common ACL injury scenarios would be managed; 3) what variations exist in surgical technique; and 4) how patient variables such as age, gender, and alignment influence the decision-making process.

RESULTS

The return rate was 72%, and 56% of respondents were from academic centers. Patients such as those described in the protocol are routinely managed by 80% of the respondents. The diagnosis of acute hemarthrosis is predominantly made by means of clinical examination and radiographs. Magnetic resonance imaging (MRI) is used occasionally by 43% and routinely by 6% of those who responded; arthroscopy is used routinely by 24%. For the competitive athlete with a complete ACL tear, 64% would recommend reconstruction and 33% would recommend bracing and rehabilitation. For reconstruction, 59% would use bone-patellar tendon-bone (B-PT-B) autograft and 32% would use hamstring tendon autograft; 40% would incorporate the ACL stump during reconstruction. Of the respondents, 77% would advocate ACL reconstruction for competitive athletes with chronic ACL injury. Of these, 63% would use B-PT-B autograft and 27% would use hamstring tendons. If bracing and rehabilitation failed, 98% would recommend ACL reconstruction. In ACL reconstruction, synthetic augmentation would be used by 12% in chronic cases and by 16% in acute cases. In making the decision to perform ACL reconstruction, 53% consider limb alignment to be important and 67% consider moderate patellofemoral pain to be important. Seventy-one percent are influenced by patellofemoral pain when choosing a surgical technique, with a trend toward semitendinosis autograft rather than B-PT-B autograft reconstruction. For the 8-year-old child with an acute ACL injury, 63% of the respondents would recommend rehabilitation and bracing. For the 14-year-old, 45% would recommend rehabilitation and bracing and 37% would recommend ACL reconstruction after physeal closure.

CONCLUSION

The results of the survey indicate that, with respect to some of the issues, there is a wide variation in management of acute and chronic ACL injuries among Canadian orthopedic surgeons. Future research and randomized, controlled clinical trials should be directed toward these areas.

Prevalence of Mycoplasma pneumoniae in children with pneumonia in Zaria, Nigeria

The prevalence of Mycoplasma pneumoniae in children suffering from pneumonia was investigated, using complement fixation and growth inhibition tests. From the sera of 104 children with pneumonia, 32 (31%) showed a CF titre greater or equal to 1:64, while all the 52 control children of the same age and sex had a CF titre less than 1:16. Children 6-10 years of age had the highest positive titre (41%) while the age groups 3-5 years and 0-2 years had positive titres of 30 and 28%, respectively. Both sexes were equally affected (33% male, 29% female). Mycoplasma pneumoniae was isolated in two children whose CF antibody titres were 1:16. It is concluded that M. pneumoniae plays an important role as an aetiological agent of pneumonia in children in Zaria, Nigeria, and could be included in the routine diagnostic protocol of pneumonia, especially during the dry harmattan months when cases of lobar pneumonia are prevalent.