Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis

Objectives

The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.

Data sources

A review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.

Methods of study selection

Observational studies (cohort/case–control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.

Tabulation, integration and results

From the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42–4.01) or ventouse (OR 2.44, 95 % CI 1.83–3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24–2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06–2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1–1.35).

Conclusion

The overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.

     

Changes in matrix phosphorylation during bovine dentin development

Phosphorylation of the organic matrix proteins of dentin is important for the initiation of mineralization, but its relevance in later mineralization stages is controversial. The objective of this study was to analyze changes in the total matrix phosphate content during dentin development and to identify their origin. Amino acid and total matrix phosphate analyses of microdissected developing mantle and circumpulpal fetal bovine dentin specimens were performed. The amino acid composition showed few changes during mantle and circumpulpal dentin maturation. However, the total matrix phosphate content showed a significant, positive correlation with tissue maturation in both mantle and circumpulpal dentin, with a two- and a three-fold increase, respectively, being observed. The data indicate that changes occur in the pattern of phosphorylation of matrix proteins during dentin maturation, which we suggest may play a functional role in later stages of tooth mineralization.     

Endoscopic endonasal versus transcranial approach to resection of olfactory groove meningiomas: a systematic review

Neurosurgical Review - Despite the increasing utility of the endoscopic endonasal approach (EEA) for management of anterior skull base (ASB) pathologies, the optimal treatment strategy for...     

Hypoglycemia - A rare complication of carbamazepine overdose

Carbamazepine overdose usually presents with neurological manifestations such as ataxia, seizures and altered sensorium or cardiac manifestations that include tachycardia, hypotension and ventricular extra-systoles. We report a patient with carbamazepine overdose who manifested recurrent hypoglycemia on the third and fourth day following ingestion that resolved with supportive therapy.KEY WORDS: Anti-epileptic, carbamazepine, complication, hypoglycemia, overdose     

Diverticular per oral endoscopic myotomy (DPOEM) for esophageal diverticular disease: a systematic review and meta-analysis

The traditional way to tackle Zenker’s diverticulum (ZD) has been flexible endoscopic septum division (FESD). Recently, the concept of per oral endoscopic myotomy has been found useful for managing diverticular diseases of the esophagus and has been termed DPOEM. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of D-POEM in diverticular disease of the esophagus and to compare it with FESD. We systematically searched PubMed and Embase, for studies reporting clinical success, technical success and adverse events in D-POEM alone or D-POEM comparing with FESD. We computed pooled prevalence for D-POEM alone and risk ratio for D-POEM vs FESD using random effect method with inverse variance approach. Subgroup analysis for ZD, non-ZD and mixed diverticulum was conducted. Totally 19 studies including 341 patients were identified reporting on D-POEM. The pooled clinical, technical success and adverse event rates for D-POEM were 87.07%, 95.19% and 10.22%, respectively. The clinical success was significantly better than FESD while the technical success, adverse event rate, procedure time and length of hospital stay were comparable with FESD. The recurrence rate was negligible for D-POEM compared to FESD. On subgroup analysis by dividing into three groups of ZD, non-ZD and mixed, there was no difference between clinical, technical success and adverse event rate among the three groups. D-POEM is an effective and safe technique among both ZD and non-ZD patients and has better clinical success than FESD.

     

Gender and utilization of ancillary services

OBJECTIVE: To determine whether gender is associated with the use of ancillary services in hospitalized patients. DESIGN: A retrospective study of laboratory and radiology tests ordered for medical and surgical inpatients over 16-month and 20-month periods, respectively. Obstetric patients were excluded. MEASUREMENTS AND MAIN RESULTS: Number of clinical laboratory and radiology tests per admission, their associated charges, and total charges per admission were measured. In crude analyses, women had 16.5% fewer clinical laboratory tests (p < .0001) with 18.8% lower associated charges (p < .0001) and 24.4% fewer radiology tests (p < .0001) with 15.6% lower associated charges (p < .0001) than men. Total changes for the admission were lower for women in both the clinical laboratory study period ($16,178 vs $18,912, p < .0001) and the radiology study period ($14,621 vs $18,182, p < .0001). When adjusted for age, race, insurance status, service, diagnosis-related-group weight, and length of stay, these differences were smaller but persisted: women had 3.7% fewer laboratory tests performed (p < .001) with 4.8% lower associated charges (p < .001). In similarly adjusted analyses for radiology studies, women received 10.4% fewer radiology examinations (p < .001), with 4.1% lower associated charges (p < .01). There were no significant differences in the adjusted total charges in the laboratory group ($17,450 vs $17,655, p=.20) and only a marginally significant difference in the radiology group ($16,278 vs $16,498, p = .05). When we compared ancillary utilization within the five largest diagnosis-related groups, these differences persisted. CONCLUSIONS: Men receive more ancillary services than women, even after adjusting for potential confounders. This study was supported by research grant R01-HS07107-01 from the Agency for Health Care Policy and Research. Dr. Jha was supported in part by the Carl W. Walter fund of Harvard Medical School.     

Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) joint consensus statement for MR imaging of placenta accreta spectrum disorders

This study was conducted in order to establish the joint Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) guidelines on placenta accreta spectrum (PAS) disorders and propose strategies to standardize image acquisition, interpretation, and reporting for this condition with MRI. The published evidence-based data and the opinion of experts were combined using the RAND–UCLA Appropriateness Method and formed the basis for these consensus guidelines. The responses of the experts to questions regarding the details of patient preparation, MRI protocol, image interpretation, and reporting were collected, analyzed, and classified as “recommended” versus “not recommended” (if at least 80% consensus among experts) or uncertain (if less than 80% consensus among experts). Consensus regarding image acquisition, interpretation, and reporting was determined using the RAND–UCLA Appropriateness Method. The use of a tailored MRI protocol and standardized report was recommended. A standardized imaging protocol and reporting system ensures recognition of the salient features of PAS disorders. These consensus recommendations should be used as a guide for the evaluation of PAS disorders with MRI. • MRI is a powerful adjunct to ultrasound and provides valuable information on the topography and depth of placental invasion. • Consensus statement proposed a common lexicon to allow for uniformity in MRI acquisition, interpretation, and reporting of PAS disorders. • Seven MRI features, namely intraplacental dark T2 bands, uterine/placental bulge, loss of low T2 retroplacental line, myometrial thinning/disruption, bladder wall interruption, focal exophytic placental mass, and abnormal vasculature of the placental bed, reached consensus and are categorized as “recommended” for diagnosing PAS disorders.