Position paper on olfactory dysfunction: 2023

BACKGROUND

Since publication of the original Position Paper on Olfactory Dysfunction in 2017 (PPOD-17), the personal and societal burden of olfactory disorders has come sharply into focus through the lens of the COVID-19 pandemic. Clinicians, scientists and the public are now more aware of the importance of olfaction, and the impact of its dysfunction on quality of life, nutrition, social relationships and mental health. Accordingly, new basic, translational and clinical research has resulted in significant progress since the PPOD-17. In this updated document, we present and discuss currently available evidence for the diagnosis and management of olfactory dysfunction. Major updates to the current version include, amongst others: new recommendations on olfactory related terminology; new imaging recommendations; new sections on qualitative OD and COVID-19 OD; updated management section. Recommendations were agreed by all co-authors using a modified Delphi process.

CONCLUSIONS

We have provided an overview of current evidence and expert-agreed recommendations for the definition, investigation, and management of OD. As for our original Position Paper, we hope that this updated document will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency, and generalisability of work in this field.

Effect of Administrating Coenzyme Q10 with Clomiphene Citrate on Ovulation Induction in Polycystic Ovary Syndrome Cases with Resistance to Clomiphene Citrate: A Randomized Controlled Trial

Background:

The purpose of this study was to assess the effect of combining low dose of Coenzyme Q10 with clomiphene citrate on ovulation induction in polycystic ovary syndrome (PCOS) women with clomiphene resistance.

Methods:

A total of 149 women with clomiphene resistant PCOS who needed ovulation induction were randomly allocated to oral clomiphene citrate and Coenzyme Q10 group and oral clomiphene citrate only group using a computer generated allocation sequence. The study was conducted at Aziz Medical Center, Karachi, Pakistan from 1st July 2020 to 1st October 2020. Polycystic ovary syndrome was diagnosed according to Rotterdam criteria. The primary outcome was ovulation and conception rate per cycle. Chi square test and Fischer’s exact test were used to compare these variables at p<0.05 level of significance.

Results:

Of the 133 women assessed, the proportion of women who ovulated with combination (70% vs., 19%, p=0.001) was greater and the combination group had greater conception rate per cycle than those who received only clomiphene (48.6% vs. 6.3%, p<0.001). When stratified according to obesity, 85.3% of non-obese women who received combination ovulated whereas only 55.6% of obese women ovulated (p=0.002). Moreover, 48.6% of non-obese women conceived in the combination group as compared to 6.3% of obese women (p=0.007). Women who received combination were six times more likely to conceive than women who only received clomiphene citrate (AOR=6.344, 95% CI: 1.452–27.71, p=0.014).

Conclusion:

Coenzyme Q10 is a valuable adjunct in women with PCOS undergoing ovulation induction. It improves ovulation and conception in women with clomiphene resistance.

Triaging Women with Pregnancy of Unknown Location: Evaluation of Protocols Based on Single Serum Progesterone, Serum hCG Ratios, and Model M4

Background:

The purpose of the current study was to evaluate the ability of three protocols to triage women presenting with pregnancy of unknown location (PUL).

Methods:

Women with pregnancy of unknown location were recruited from Aziz Medical Centre from 1st August, 2018 to 31st July, 2020. The criterion of progesterone, human chorionic gonadotrophin (hCG) ratio, and M4 algorithm were used to predict risk of adverse pregnancy outcomes and classify women. Finally, 3 groups were established including ectopic pregnancy, failed pregnancy of unknown location, and intrauterine pregnancy (IUP). The primary outcome was to assign women to ectopic pregnancy group using these protocols. The secondary outcome was to compare the sensitivity and specificity of the three protocols relative to the final outcome.

Results:

Of the 288 women, 66 (22.9%) had ectopic pregnancy, 144 (50.0%) had intrauterine pregnancy, and 78 (27.1%) had failed pregnancy of unknown location. The criterion of progesterone had a sensitivity of 81.8%, specificity of 27%, negative predictive value (NPV) of 83.3%, and positive predictive value (PPV) of 25% for high risk result (ectopic pregnancy). The hCG ratio had sensitivity of 72%, specificity of 73%, NPV of 90%, and PPV of 44% for high risk result (ectopic pregnancy). However, model M4 had sensitivity of 86.4%, specificity of 91.9%, NPV of 95.8%, and PPV of 76% for high risk result.

Conclusion:

Based on the findings of the study, it was revealed that prediction model of M4 had the highest sensitivity, specificity, negative predictive value and positive predictive value for high risk result (ectopic pregnancy).

Pregnant during the COVID-19 pandemic: Knowledge, concerns, attitudes and practices of Pakistani women

INTRODUCTION

Data regarding pregnancy and related outcomes with COVID-19 are inconsistent, which leads to difficulties in counselling pregnant women. This brings uncertainty to pregnant women regarding mode of birth, transmission and issues that may occur in case they contract the disease. We conducted this study to assess the knowledge about COVID-19 risk during pregnancy and childbirth and to assess the concerns, attitudes, and practices of pregnant women during the pandemic.

METHODS

A cross-sectional survey was carried out among 376 consenting pregnant women attending antenatal clinics in Karachi, Pakistan, between 1 July and 16 July 2020, using pretested questionnaires.

RESULTS

A total of 376 pregnant women participated in the survey. Participants had inadequate knowledge about COVID-19 risk during pregnancy, including potential vertical transmission (58.5%), preferred route of delivery (52%), safety of breastfeeding (50%), birth defects (44.7%), rooming in and skin-to-skin contact (58.5%). The majority (85.1%) had a high concern score, and negative attitude (62.8%). Only 43.6% said that they would not hide their symptoms, while 37.2% stated that they will deliver at hospital if they tested positive. Only 30.9% of respondents had good practices. During visits, 39.4% maintained social distancing and sanitized hands while only 37.2% said that they did not bring more than one person with them.

CONCLUSIONS

The study population had inadequate knowledge, negative attitude, and poor practices regarding pregnancy during the COVID-19 pandemic. More than half of the respondents thought that concealing symptoms and delivering at home would be better. Awareness programs are urgently needed.

Anti-phospholipid antibodies in women presenting with preterm delivery because of preeclampsia or placental insufficiency

Objective:

To assess the proportion of women presenting with preterm delivery because of preeclampsia or placental insufficiency (PREPI) with anti-phospholipid antibodies (APLA).

Material and Methods:

This was a prospective cohort study conducted at an obstetrics and gynecology department. Women, aged 20-40 years, with preeclampsia who delivered before 34 weeks were cases while those who delivered before 34 weeks but did not have preeclampsia acted as controls. Both groups had APLA measured at diagnosis and 12-weeks postnatally. Anti-phospholipid antibody syndrome (APS) was diagnosed according to Sapporo’s criteria.

Results:

The study included 98 cases and 106 controls. Both cases and controls were similar in terms of age, gestational age and parity. The frequency of APS positivity was 17.3% in cases but only 3.8% in controls (p=0.001). Cases were more likely to be of Baloch ethnicity (34.7% vs. 11.3%, p=0.001), have a history of miscarriage (25.5% vs. 13.2%, p=0.026), use aspirin (p<0.001) or low molecular weight heparin (p<0.001), and be obese (p<0.001) than controls. Cases were more likely to have lupus anticoagulant antibodies (82.4% vs. 75%).

Conclusion:

Our study confirms a high prevalence of APLA in women who have preterm delivery due to PREPI. An opportunity to screen these women should be made, so that proper counselling can be given and future pregnancies can be managed in an appropriate and timely manner.

Frequency of pregnant women who accept HIV screening using rapid detection test and factors associated with acceptance

To assess the frequency of pregnant women who accept HIV screening using rapid detection test and factors associated with acceptance we undertook a cross-sectional study conducted from July to December 2018. Women aged 20–45 years, who were pregnant and planned to deliver at the facility, were included. Women were counseled and offered about Human Immunodeficiency virus (HIV) screening. A total of 718 women were included in the study. The screening was accepted by 32.3% of women. Six women tested positive in the study giving a seroprevalence of 0.8% in the population studied. Acceptance of counseling and screening varied significantly with age range, educational status, socioeconomic status, and employment status. Women aged 30 years and above ( p = 0.023) and women with higher education ( p < 0.001) were more likely to refuse counselling. Similarly, employed women (p = 0.041) and women of higher socioeconomic class ( p = 0.039) refused counselling. However, when logistic regression was conducted, only educational status ( p < 0.001) and occupational status ( p = 0.039) were significantly associated with acceptance of counseling and screening. The acceptance of counselling and testing for HIV in antenatal care attendees was low. Women of higher educational status and having some employment refused counselling and testing more commonly.

Knowledge and practices: Risk perceptions of COVID-19 and satisfaction with preventive measures at workplace among maternity care providers in Pakistan

INTRODUCTION

While all healthcare services across the globe deferred non-urgent surgeries, labor wards provided maternity care during the COVID-19 pandemic continuously. This study assesses the knowledge and practices of obstetricians and midwives about personal protective equipment (PPE); their risk perception of COVID-19 and satisfaction with the preventive measures adopted at their workplace.

METHODS

A questionnaire designed according to the World Health Organization’s advice on rational use of personal protective equipment for COVID-19 was administered to 452 Pakistani maternity care providers between 1 July and 30 July 2020.

RESULTS

Most (85%) had adequate knowledge and 78.8% had good practices regarding PPE use. The perceived risk of contracting COVID-19 was lower than for influenza and tuberculosis. Perceived risk of contracting COVID-19 was highest for outpatient clinics. Fewer midwives compared to obstetricians (23.3% vs 32.9 %, p=0.001) were satisfied with the job security provided. Only 19.5% were satisfied with the social distancing measures at their setups. Less than one-third (31%) were satisfied with the PPE available to them.

CONCLUSIONS

The participants had good knowledge and practices regarding PPE. The perceived risk of contracting COVID-19 was lower than for contracting influenza; however, they were concerned about contracting COVID-19 in outpatient clinics and emergency rooms. They had poor satisfaction with the measures adopted by hospital managements regarding job security and social distancing.

Pessary offer documentation in women undergoing surgery for pelvic organ prolapse at a tertiary care hospital

BACKGROUND

Women report similar functional outcomes after pessary treatment or surgery for pelvic organ prolapse (POP).

AIMS

To assess the documentation of pessary counselling in women who underwent surgery for POP. Methods: This was a retrospective cohort study conducted on women who underwent hysterectomy for prolapse. The primary outcome measure was documentation regarding offer of pessary. 'Pessary offer' was defined as documentation that clearly stated that the care provider offered pessary to the patient.

FINDINGS

Over the study period, 81 hysterectomies took place for POP; pessary offer was documented for only 19 (23.5%) case records. Characteristics significantly associated with pessary offer were history of chronic cough (P=0.031), previous pelvic surgery (P<0.001), no secondary indication for surgery (P=0.012), concomitant surgery performed other than hysterectomy (P=0.046), age range (P<0.001) and BMI range (P<0.001).

CONCLUSION

Pessary offer was documented in less than quarter of cases. This denotes a need to strengthen documentation of offer, counselling for pessary, or both of these.

Femiject, a once-a-month combined injectable contraceptive: experience from Pakistan

OBJECTIVES

The aims of the study were to compare the 12 month continuation rate, level of satisfaction and bleeding patterns of a once-a-month combined injectable contraceptive (CIC; Femiject), a 3 monthly progestogen-only injectable contraceptive (depot medroxyprogesterone acetate [DMPA]) and combined oral contraceptives (COCs).

METHODS

A prospective observational study was conducted at Aziz Medical Centre, Karachi, Pakistan. The study comprised 171 married women aged 19-35 years and requesting contraception. Participants were offered injectable contraceptives or COCs and evaluated twice: once at the beginning of the study and again after 12 months, or earlier if they discontinued use.

RESULTS

Sixty (35.1%) women chose COCs, 53 (31.0%) chose DMPA and 58 (33.9%) chose the CIC. The continuation rate was higher among CIC users (p = .034). CIC users were more satisfied with their method compared with those who chose COCs or DMPA (63.8% vs 25.0% and 28.3%, respectively). Most CIC users said they were likely or very likely to use the method again (63.8%); only 25.9% said they would not recommend it to a friend. CIC users had, however, more spotting compared with COC users (60.3% vs 3.3%; p ˂ .001).

CONCLUSION

As the continuation rate, level of satisfaction and bleeding profile of CIC users was promising, increased uptake should be encouraged. Our study shows that CIC is a good option for women requesting contraception.

Cervical stenosis and pregnancy rate after ultrasound guided cervical dilation in women undergoing saline infusion sonography

Aim

To assess the effect of ultrasound-guided cervical dilation on clinical pregnancy rates in women with cervical stenosis.

Methods

A prospective case control study was conducted in women with unexplained infertility. These women underwent saline infusion sonography and were suspected of having cervical stenosis if a 7 French Foley’s catheter could not be introduced into the cervical canal. Women with suspected stenosis who agreed to undergo ultrasound guided dilation were included as cases. Those with suspected stenosis who refused dilation were used as controls. Both groups were followed for one year. The primary outcome measure was women who had clinical pregnancy i.e. fetal heart beat present on transvaginal scan during the follow up period.

Results

During the study period, 1097 women who underwent SIS were included. A total of 117 (10.7%) patients had cervical stenosis. No statistically significant difference was there in both groups in terms of mean age (p = 0.617), mean body mass index (p = 0.598), duration of infertility (p = 0.588) and type of infertility (p = 0.167). However, both groups were significantly different in terms of history for risk factors i.e. endometriosis (p <0.001), prior surgery (p <0.001), polyps (p = 0.004) and pelvic inflammatory disease (p = 0.001). Eighty-nine women agreed to have dilation and were used as cases and 28 women refused and were used as controls. Of the cases, 70.45% conceived as compared to 18.5% of controls. The mean time to conception in months was also significantly lower in cases (8.10 ± 3.43 vs. 11.39 ± 1.97, p <0.001).

Conclusions

Our study shows that ultrasound-guided cervical dilation in women with cervical stenosis can lead to improved conception rates.

European Position Paper on Rhinosinusitis and Nasal Polyps 2020

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 is the update of similar evidence based position papers published in 2005 and 2007 and 2012. The core objective of the EPOS2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations and integrated care pathways in ARS and CRS. EPOS2020 provides an update on the literature published and studies undertaken in the eight years since the EPOS2012 position paper was published and addresses areas not extensively covered in EPOS2012 such as paediatric CRS and sinus surgery. EPOS2020 also involves new stakeholders, including pharmacists and patients, and addresses new target users who have become more involved in the management and treatment of rhinosinusitis since the publication of the last EPOS document, including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition using over the counter treatments. The document provides suggestions for future research in this area and offers updated guidance for definitions and outcome measurements in research in different settings. EPOS2020 contains chapters on definitions and classification where we have defined a large number of terms and indicated preferred terms. A new classification of CRS into primary and secondary CRS and further division into localized and diffuse disease, based on anatomic distribution is proposed. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, allergic rhinitis, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. All available evidence for the management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is systematically reviewed and integrated care pathways based on the evidence are proposed. Despite considerable increases in the amount of quality publications in recent years, a large number of practical clinical questions remain. It was agreed that the best way to address these was to conduct a Delphi exercise . The results have been integrated into the respective sections. Last but not least, advice for patients and pharmacists and a new list of research needs are included. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

22 Design and Implementation of A Nutrition Clinical Pathway for Patients with Fractured Neck of Femur

Background

Patients with a fractured neck of femur (FNOF) are commonly malnourished pre-admission, have reduced oral intake in hospital and a hypermetabolic state up to three months postoperatively (E Paillaud 2000). Malnutrition is associated with functional deterioration, higher morbidity and mortality.

Evidence suggests nutritional supplementation post-surgery can reduce postoperative complications. As a result, nutritional assessment is included in the National Hip Fracture Database best practice tariff (Avenell, Cochrane Database of Systematic Reviews 2016).

Introduction

Our aim was to design and implement a clinical pathway for patients with FNOF to identify malnutrition and provide appropriate nutritional support.

Intervention

A retrospective audit of 25 patients was completed to understand baseline rates of assessment, prescription of supplements and referral to dietetics. Using these data meetings were arranged to develop a clinical pathway. Key stakeholders included dietetics, orthopaedic surgeons, geriatricians, physiotherapists and nurses. The pathway was evaluated and optimised with two Plan-Do-Study-Act (PDSA) cycles looking at 25 patients each time.

Results

Baseline: 79% received a nutritional assessment, 32% had nutritional supplements prescribed and 36% (n=9) met criteria for referral to a dietician, of which 55%were referred. However, an additional 5 referrals were made to dietetics for patients who did not meet criteria, a 50% inappropriate referral rate.

PDSA cycle 1: increased nutritional assessment (85%), increased nutritional supplements prescribed (92%), decreased inappropriate referrals to dietetics (43%).

PDSA cycle 2: increased nutritional assessment & nutritional supplements prescribed (100%), increased inappropriate referrals to dietetics (80%).

Conclusions

The implementation of a nutrition pathway has led to increased identification and treatment of malnutrition, which has in addition improved accrual of the best practice tariff. However, greater number of inappropriate referrals have been made to dietetics. This is partly attributed to difficulty weighing patients on admission, and where no weight is inputted on the Malnutrition Universal Screening Tool a “High Risk” score is generated triggering a referral. We are now looking at alternative methods to obtaining a weight such a mid-upper arm circumference.

A comparison of antenatally and intraoperatively diagnosed cases of placenta accreta spectrum

Objective

To assess the effect of antenatal diagnosis of placenta accreta spectrum (PAS) on fetomaternal outcomes.

Material and Methods

This was a retrospective cohort study conducted from January 2017 to December 2018. Women with PAS diagnosed antenatally were designated as group A and those where diagnosis was suspected during operation and confirmed on histopathology (PAS diagnosed perioperatively) were designated as group B. Outcome in terms of uterine conservation, maternal death, admission of mother to intensive care unit (ICU), perinatal death and neonatal ICU (NICU) admission were recorded.

Results

During the study, PAS was confirmed in 96 cases which were included. Out of these, 34 (35.4%) cases were included in group A while 62 (64.6%) were diagnosed intraoperatively (group B). The median number of units of blood transfused was lower in group A compared to group B (4 vs 6, p<0.001). The uterus was conserved more often in group A compared with group B (67.6% vs 43.5%, p=0.024) while admission to ICU occurred significantly more often in group B (26.5% vs 59.7%, p=0.002). Maternal death (p=0.038) and perinatal death (p=0.008) were also significantly higher in group B. More neonates delivered to mothers in group B were admitted to NICU (85.7% vs 24%, p=0.033). Survival analysis showed a statistically significant increase in uterine conservation rate in group A compared with group B (log rank, p=0.04).

Conclusion

PAS diagnosed antenatally has better fetomaternal outcome than intraoperative detection of PAS. Diagnosing PAS antenatally is therefore crucial to improve management and achieve a better outcome.

Women's decision versus couples' decision on using postpartum intra-uterine contraceptives

Background

In conservative societies of low- and middle-income countries, the decision-making process is heavily influenced by male partners.

Aims

To assess the male partner's influence on female partner's ultimate decision regarding uptake of postpartum intrauterine contraceptive device (PPIUCD).

Methods

This was a prospective, analytical study conducted at Abbasi Shaheed Hospital, Karachi, Pakistan, from 1 March 2016 to 30 August 2016. The study included 566 pregnant women who were counselled regarding postpartum contraception (PPC) and asked to choose their preferred method. The choice was noted before and after discussion with their spouse. Discordance was assessed using McNemar's test for paired samples, taking P ≤ 0.05 as statistically significant.

Results

Among those counselled, 470 (83.03%) showed willingness to accept PPC. Out of these, 142 (30.2%) chose PPIUCD initially. After discussion with their spouse, only 82 (17.4%) accepted PPIUCD. The discordance between original decision of the woman and final decision to accept PPIUCD was statistically significant (P < 0.001).

Conclusions

The discordance between original decision and final decision shows considerable influence by males on uptake of PPIUCD.

Fertility outcome after saline sonography guided removal of intrauterine polyps in women with unexplained infertility

Objective: To assess the effect of removal of unsuspected polyps as delineated on saline sonography on the clinical pregnancy rate in women with unexplained infertility. Methodology: A prospective case control study was being conducted from 1st October 2016 to 30^th September 2018 at Aziz Medical Centre, Karachi. Women diagnosed with unexplained infertility and unsuspected polyps revealed on saline sonography were included as cases (Group A). They were offered removal of polyps under ultrasound guidance and general anesthesia. Saline sonography was repeated at the time to ensure complete removal (Izhar's Modification). Those with unsuspected polyps on saline sonography, but who refused the intervention, were classified as controls (Group B). Both groups were followed for one year. The primary outcome measure was women who had clinical pregnancy i.e. fetal heartbeat present on transvaginal scan during the follow up period. Results: During the study period, out of 92 cases, 37 (40.2%) conceived and out of 92 controls, 10 (10.9%) conceived, which proved that polypectomy increased the chances of conception four-fold (p <0.001). The mean time to conception was also significantly lower for cases than controls (9.26 ± 3.928 months vs. 11.33 ± 2.07 months, p <0.001). The cumulative pregnancy rate was significantly higher in the polypectomy group (log-rank test, p <0.001). The duration of infertility (p = 0.007), position of polyp (p = 0.049) and polypectomy (p <0.001) influenced pregnancy rate. Conclusions: Our study shows the beneficial effect of removal of polyps. Women are four times more likely to conceive spontaneously after polypectomy.

Objective: To assess the effect of removal of unsuspected polyps as delineated on saline sonography on the clinical pregnancy rate in women with unexplained infertility. Methodology: A prospective case control study was being conducted from 1st October 2016 to 30^th September 2018 at Aziz Medical Centre, Karachi. Women diagnosed with unexplained infertility and unsuspected polyps revealed on saline sonography were included as cases (Group A). They were offered removal of polyps under ultrasound guidance and general anesthesia. Saline sonography was repeated at the time to ensure complete removal (Izhar’s Modification). Those with unsuspected polyps on saline sonography, but who refused the intervention, were classified as controls (Group B). Both groups were followed for one year. The primary outcome measure was women who had clinical pregnancy i.e. fetal heartbeat present on transvaginal scan during the follow up period. Results: During the study period, out of 92 cases, 37 (40.2%) conceived and out of 92 controls, 10 (10.9%) conceived, which proved that polypectomy increased the chances of conception four-fold (p <0.001). The mean time to conception was also significantly lower for cases than controls (9.26 ± 3.928 months vs. 11.33 ± 2.07 months, p <0.001). The cumulative pregnancy rate was significantly higher in the polypectomy group (log-rank test, p <0.001). The duration of infertility (p = 0.007), position of polyp (p = 0.049) and polypectomy (p <0.001) influenced pregnancy rate. Conclusions: Our study shows the beneficial effect of removal of polyps. Women are four times more likely to conceive spontaneously after polypectomy.

Effects of oral probiotic supplements on vaginal microbiota during pregnancy: a randomised, double-blind, placebo-controlled trial with microbiome analysis

Objective

To determine the effects on the vaginal microbiota of an oral probiotic preparation administered from early pregnancy.

Design

Randomised, double blind, placebo‐controlled trial.

Setting

Four maternity units in the UK.

Population

Women aged 16 years or older recruited at 9–14 weeks' gestation.

Methods

Participants were randomly allocated to receive oral capsules of probiotic containing Lactobacillus rhamnosus GR‐1 and Lactobacillus reuteri RC‐14 each at 2.5 × 10⁹ colony‐forming units (CFUs) or placebo once daily from recruitment until the end of pregnancy.

Main outcome measure

Rates of bacterial vaginosis (BV, defined as Nugent score ≥7) at 18–20 weeks' gestation compared by logistic regression adjusted for possible confounders.

Results

The primary analysis included 78% (238/304) of participants who initially consented (probiotic group 123, placebo group 115). Of these participants, 95% (227/238) reported an intake of 93% or more of the required number of capsules. The rates of BV did not differ between groups at 18–20 weeks' gestation (15% (19/123) in the probiotic group vs. 9% (10/115) in the placebo group, adjusted odds ratio 1.82, 95% confidence interval 0.64–5.19). There were also no differences between the groups in the proportion of women colonised with the probiotic strains, Escherichia coli, group B streptococci or other vaginal microbiota. There were no differences in the alpha diversity or composition of the bacterial communities between or within the probiotic and placebo groups at 9–14 and 18–20 weeks’ gestation.

Conclusions

Oral probiotics taken from early pregnancy did not modify the vaginal microbiota.

Tweetable abstract

The oral probiotic preparation used in this study does not prevent BV in pregnant women.

The oral probiotic preparation used in this study does not prevent BV in pregnant women.

Analytical and computational studies of the nonlinear vibrations of SWCNTs embedded in viscous elastic matrix using KBM method

The forced vibration analysis of single wall carbon nanotubes (SWCNTs) embedded in the viscous elastic matrix subjected to axial parametric excitation has been investigated. The Euler Bernoulli beam model of the non-local continuum theory is used. The resonant and non-resonant solutions are analytically studied using the Krylov Bogoliubov and Mitropolsky method. It has been seen that the amplitude remains constant up to the second order of approximation. The resonant solutions are also found to analyze the possibility of chaos in the neighborhood of resonance. The computational techniques are used, and plots of time series, phase plot, and Poincaré surface of section are also drawn to confirm the chaotic behavior for certain values of parameters of SWCNTs, which may lead the aging process in the SWCNTs after a long time.

Internal carotid artery injury during endonasal sinus surgery: our experience and review of the literature

Iatrogenic internal carotid artery injury is a catastrophic but uncommon complication of endonasal sinus surgery. We present our experience in managing this emergency situation. A 52-year-old man underwent revision endoscopic repair of recurrent cerebrospinal fluid leak that was complicated with profuse haemorrhage during removal of the anterior wall of sphenoid sinus using a Hajek sphenoid punch forceps. Immediate packing of the sphenoid sinus controlled the haemorrhage. Urgent angiography revealed injury at the paraclival segment of the left internal carotid artery. An endovascular stent was initially placed but thrombosed; it was subsequently converted to coil embolisation. The patient had watershed cerebral infarct with hemiparesis post procedure but made full recovery within 6 weeks. Immediate nasal packing followed by urgent angiography and endovascular stent placement is the least invasive definitive treatment. If stenting is unsuccessful, endovascular balloon occlusion or coil embolisation is the next preferred treatment, if there is adequate cross-cerebral circulation. The success of treatment relies on its immediate management by a multidisciplinary team.

Incidence of intrauterine abnormalities in Pakistani women with unexplained infertility diagnosed via saline infusion sonography

To determine the frequency of intrauterine abnormalities in women with unexplained infertility using saline infusion sonography. This was a retrospective cohort study conducted at Aziz medical centre, Karachi, Pakistan between January and December 2015. The study population comprised of women with unexplained infertility who underwent saline infusion sonography as a part of their diagnostic workup. The frequency of uterine abnormalities in these women was determined and the relationship between these pathologies and patient age and body mass index was assessed. Of the 769 women included, 202 (26.3%) had uterine abnormalities. Endometrial polyp (118 cases, 15.3%) was the most common abnormality, followed by submucous fibroids (54, 7%), intrauterine adhesions (20, 2.6%), and septae (10, 5%). Intrauterine pathologies were more common in women with primary infertility (71.8% versus 28.2%, p = 0.002). Uterine abnormalities were most common in the age group 30-34 years ( n = 80, 39.6%) and in overweight patients ( n = 95, 47%). The distribution of abnormalities differed significantly in various age groups ( p = 0.009) and among women with different BMI ( p = 0.029). A significant number of women with unexplained infertility present with unsuspected uterine abnormalities; therefore an assessment of the uterine cavity should be performed in all cases.

An Overview of Menopausal Symptoms Using the Menopause Rating Scale in a Tertiary Care Center

CONTEXT

Due to increased life expectancy worldwide, women are expected to spend a significant portion of their lives in menopause. Proven prevention strategies against serious risks and tested effective treatments for common symptoms may remain unutilized in our population if these women are not asked about these symptoms.

AIM

This study aims to assess the prevalence of different menopausal symptoms and their severity according to menopause rating scale (MRS) in women.

SETTING AND DESIGN

The present study was a cross-sectional survey, conducted in the outpatient department of gynecology and obstetrics.

SUBJECTS AND METHODS

After written and informed consent, 121 women having their last menstrual period at least 1 year ago were included. The menopausal symptoms were assessed using the MRS. The primary outcome measure in this study was the prevalence of menopausal symptoms in these women according to MRS and the severity of these symptoms.

STATISTICAL ANALYSIS USED

Data were analyzed using the SPSS software program, version 15.0 (IBM, Armonk, New York, USA).

RESULTS

The most common symptom was mental and physical exhaustion which was reported by 88 (72%) women, followed by joint and muscular discomfort which was reported by 83 (68.59%). Hot flushes were reported by 54 (44.62%) respondents. Majority of women reported mild-to-moderate symptoms.

CONCLUSIONS

The prevalence of menopausal symptoms is high, and a health policy needs to be generated for the region.

Differential gene expression in trigeminal ganglia of male and female rats following chronic constriction of the infraorbital nerve

BACKGROUND

The mechanisms underlying sex-based differences in pain and analgesia are poorly understood. In this study, we investigated gene expression changes in trigeminal ganglia (TG) of male and female rats exposed to infraorbital nerve chronic constriction injury (IoN-CCI).

METHODS

Somatosensory assessments were performed prior to IoN-CCI and at selected time points postsurgery. Selected gene expression changes were examined with real-time quantitative polymerase chain reaction (RT-PCR) in ipsilateral TG at 21 days postsurgery.

RESULTS

Rats exposed to IoN-CCI developed significant mechanical allodynia and hyperalgesia on days 19 and 21 postsurgery. During this period, females developed significantly more allodynia but not hyperalgesia compared to males. At 21 days postsurgery, expression levels of 44 of the 84 investigated pain-related genes in ipsilateral TG were significantly regulated relative to naïve rats in either sex. Csf1 and Cx3cr1 were up-regulated in both sexes, but the magnitude of regulation was significantly higher in females (p = 0.02 and p = 0.001, respectively). Htr1a and Scn9a were down-regulated in both sexes, but the down-regulation was significantly more pronounced in males (p = 0.04 and p = 0.02, respectively). Additionally, Cck, Il1a, Pla2g1b and Tnf genes were significantly regulated in females but not in males, and Chrna4 gene was significantly down-regulated in males but not in females.

CONCLUSIONS

Our findings suggest sex-dependent gene regulation in response to nerve injury, which may contribute to sex dimorphism of trigeminal neuropathic pain. Further studies are needed to establish gene expression changes over time and correlate these with hormonal and other physiological parameters in male and female.

SIGNIFICANCE

We present novel sex-specific transcriptional regulation in trigeminal ganglia that may contribute to male-/female-based differences in trigeminal neuropathic pain. These findings are expected to open new research horizons, particularly in male versus female targeted therapeutic regimens.

Management of rhinosinusitis in adults in primary care

Rhinosinusitis is a common health problem encountered in primary care. It is due to mucosal inflammation of the nose and paranasal sinuses. Less than 2% of the cases are associated with bacterial infections. Diagnosis is based on clinical symptoms and supported by nasal endoscopy and imaging studies. Intranasal corticosteroids and normal saline irrigation are important treatments. Antibiotics are seldom indicated.

Differential gene expression in trigeminal ganglia of male and female rats following chronic constriction of the infraorbital nerve

BACKGROUND

The mechanisms underlying sex-based differences in pain and analgesia are poorly understood. In this study, we investigated gene expression changes in trigeminal ganglia (TG) of male and female rats exposed to infraorbital nerve chronic constriction injury (IoN-CCI).

METHODS

Somatosensory assessments were performed prior to IoN-CCI and at selected time points postsurgery. Selected gene expression changes were examined with real-time quantitative polymerase chain reaction (RT-PCR) in ipsilateral TG at 21 days postsurgery.

RESULTS

Rats exposed to IoN-CCI developed significant mechanical allodynia and hyperalgesia on days 19 and 21 postsurgery. During this period, females developed significantly more allodynia but not hyperalgesia compared to males. At 21 days postsurgery, expression levels of 44 of the 84 investigated pain-related genes in ipsilateral TG were significantly regulated relative to naïve rats in either sex. Csf1 and Cx3cr1 were up-regulated in both sexes, but the magnitude of regulation was significantly higher in females (p = 0.02 and p = 0.001, respectively). Htr1a and Scn9a were down-regulated in both sexes, but the down-regulation was significantly more pronounced in males (p = 0.04 and p = 0.02, respectively). Additionally, Cck, Il1a, Pla2g1b and Tnf genes were significantly regulated in females but not in males, and Chrna4 gene was significantly down-regulated in males but not in females.

CONCLUSIONS

Our findings suggest sex-dependent gene regulation in response to nerve injury, which may contribute to sex dimorphism of trigeminal neuropathic pain. Further studies are needed to establish gene expression changes over time and correlate these with hormonal and other physiological parameters in male and female.

SIGNIFICANCE

We present novel sex-specific transcriptional regulation in trigeminal ganglia that may contribute to male-/female-based differences in trigeminal neuropathic pain. These findings are expected to open new research horizons, particularly in male versus female targeted therapeutic regimens.