Assisted Reproduction Technology In A Resource-Limited Setting

No Abstrac

Posterior sagittal rectopexy in the treatment of recurrent rectal prolapse in children Amel Abd

Background/purpose Several surgical techniques have been described to treat recurrent rectal prolapse in children after failure of initial surgical treatment. The aim of this study was to evaluate the safety and efficacy of posterior sagittal rectopexy (PSR) in children with recurrent rectal prolapse.Patients and methods Twenty-two patients aged between 1 and 7 years presented with recurrent rectal prolapse after failure of initial surgical treatment. Conservative management was successful in four cases. Eighteen were treated with PSR. The procedure included plication of the dilated rectum and fixation of the rectum to the sacrum. The follow-up ranged between 4 and 18 months.Results Superficial wound infection occurred in two cases, and both healed without any further consequences. Constipation improved in seven out of 12 patients, who had history of constipation before surgery. Partial mucosal prolapse recurrence occurred in three patients. Two improved conservatively after 5 months and 7 months, respectively, and one required mucosal trimming. Normal anorectal continence was noted in all patients older than 3 years at follow-up.Conclusion PSR is a good option in cases of recurrent rectal prolapse in children. The technique is both safe and effective. It is associated with satisfactory functional results.Keywords: children, complications, posterior sagittal rectopexy, rectal prolapse, recurren

Evolution of management of gastroschisis

Background/purpose The management protocols and outcome of neonates with gastroschisis have improved significantly during the past two decades. The purpose of this study was to evaluate the evolution in management and outcome of gastroschisis in our institution. Materials and methods All patients treated for gastroschisis during the past 12 years were included. These patients were divided into two chronologically distinct groups. Group I included patients who were treated from 1998 to 2005 and group II included patients who were treated from 2005 to 2010. Each group was further subdivided into two subgroups according to the method of closure of the abdominal wall by either primary (group IA and group IIA) or delayed primary closure of the abdominal wall defect after temporary extra-abdominal hosting of the bowel using hand-sewn silastic or plastic sheets (group IB) or a spring-loaded silo (group IIB). Each patient was evaluated with regard to time spent on ventilator, time to initiating enteral feeds, time to discharge from the Neonatal Intensive Care Unit, and any complications. Results There was no difference between the two main groups with regard to the gestational age, sex, mode of delivery, or the percentage of associated congenital anomalies. Primary closure was feasible in 29 patients (18 in group IA and 11 in group IIA). Staged reduction of the herniated bowel and delayed repair were performed in 23 patients (12 in group IB and 11 in group IIB). Reduction of the herniated bowel and delayed staged reduction were performed earlier in group IIB than in group IB. Enteral feeding was earlier in patients who had primary closure either in group IA or group IIA compared with patients treated with delayed closure in either group IB or group IIB. Enteral feeding was relatively earlier in group IIB than in group IB, but the difference was not significant. Conclusion The overall morbidity and mortality showed significant improvement in the management of gastroschisis at our practice. The introduction of springloaded silo has simplified the management of patients born with gastroschisis who cannot be treated with primary reduction. Primary closure continued to have better outcome measures compared with staged closure.Keywords: abdominal wall defect, complications, gastroschisis spring-loaded sil

The Impact of Removable Partial Dentures on the Health of Oral Tissues: A Systematic Review

Objectives: The aim of the present study was to review the available literature data to identify relevant studies for inclusion and to verify whether there is evidence to support the hypothesis that the insertion of an RPD into the oral cavity has a deterioration effect on the oral health status. Materials and methods: 570 articles were identified, from searching both electronic databases (e.g., PUBMED) and manual searching of relevant written journals using an agreed search protocol up to 31st December 2011. The extraction of data for inclusion was conducted by two independent reviewers. The main outcomes of intervention involved both methodology and assessment tools applied by investigators to assess the effect of a RPD in terms of plaque accumulation, caries incidence, and gingival tissue (inflammation). Results: 401 articles were excluded following an initial screening; 169 articles were included for the further review. At a second round screening, 163 articles were also rejected and six (Randomised Clinical Trials [RCTs]) articles were eventually accepted for inclusion. Based on the results, there was some scientific evidence supporting the hypothesis that RPDs placement may increase plaque accumulation and gingival inflammation. The importance of an established prevention program for RPD wearers (including good plaque control and OHI) either prior to or during treatment was emphasised by all investigators in the included studies. Among the limitations, however when evaluating the data, was the lack of homogeneity between the included studies (e.g., study design and duration, calibration details, clinical parameters to be evaluated, reporting of dropout rates and treatment intervention). Conclusion: The conclusion from this present review would indicate that there were insufficient RCTs to adequately address the original research question, although a number of suggestions may be recommended. There was no doubt from the evidence presented in the published literature that in the absence of good oral hygiene measures a RPD may promote accumulation of the plaque which may in turn lead to gingival inflammation. Furthermore, there also appears to be a higher risk of dental caries (particularly root caries) in RPD wearers in the absence of good oral hygiene measures. The importance of an integrated prosthodontics maintenance programme with regular recall visits including both oral and denture hygiene care of a RPD cannot be under-estimated and should be adopted as a gold standard in general dental practice

Rapid detection of Mycobacterium ulcerans with isothermal recombinase polymerase amplification assay.

Background Access to an accurate diagnostic test for Buruli ulcer (BU) is a research priority according to the World Health Organization. Nucleic acid amplification of insertion sequence IS2404 by polymerase chain reaction (PCR) is the most sensitive and specific method to detect Mycobacterium ulcerans (M. ulcerans), the causative agent of BU. However, PCR is not always available in endemic communities in Africa due to its cost and technological sophistication. Isothermal DNA amplification systems such as the recombinase polymerase amplification (RPA) have emerged as a molecular diagnostic tool with similar accuracy to PCR but having the advantage of amplifying a template DNA at a constant lower temperature in a shorter time. The aim of this study was to develop RPA for the detection of M. ulcerans and evaluate its use in Buruli ulcer disease. Methodology and principal findings A specific fragment of IS2404 of M. ulcerans was amplified within 15 minutes at a constant 42°C using RPA method. The detection limit was 45 copies of IS2404 molecular DNA standard per reaction. The assay was highly specific as all 7 strains of M. ulcerans tested were detected, and no cross reactivity was observed to other mycobacteria or clinically relevant bacteria species. The clinical performance of the M. ulcerans (Mu-RPA) assay was evaluated using DNA extracted from fine needle aspirates or swabs taken from 67 patients in whom BU was suspected and 12 patients with clinically confirmed non-BU lesions. All results were compared to a highly sensitive real-time PCR. The clinical specificity of the Mu-RPA assay was 100% (95% CI, 84–100), whiles the sensitivity was 88% (95% CI, 77–95). Conclusion The Mu-RPA assay represents an alternative to PCR, especially in areas with limited infrastructure. Author summary Current diagnostic methods to detect M. ulcerans suffer from delayed time-to-results in most endemic countries by the prolonged period of time for the shipment and storage of samples to a distant, centralized laboratory. The M. ulcerans recombinase polymerase amplification assay (Mu-RPA) is a new, rapid diagnostic test developed for the detection of M. ulcerans infection, known commonly as Buruli ulcer, a chronic, debilitating, necrotizing disease of the skin and soft tissues. This assay is suitable for use on a portable detection device, with the potential to be used for quick diagnosis at the point of need, providing timely results to health workers at Buruli ulcer treatment clinics

Spontaneous latent phase labour: A review of issues in definition, classification and management options

Latent phase labour has been a subject of controversy since the time of the original concept over 5 decades ago by Friedman and this controversy is still persisting till date. There is presently so much of new knowledge of labour which when applied to latent phase may clear several of the grey areas particularly in the definition and diagnosis. However, there is still substantial debate and heat in the areas of classification and the management of latent phase where for now there is still no consensus. This review has attempted to throw more light on the grey areas in thedefinition and diagnosis by reviewing the original studies by Friedman, Hendricks and O'Driscoll who are the lead scholars in the evolutionary history of latent phase labour. The studies of several other workers in the debate on classification and management were critically review with a view to evolve a consensus. It is finally concluded that nowadays latent phase labour is a clinically recognizable entity with clear cut features and parameters for a prospective diagnosis. Also in spite of the current debate, it is suggested that latent phase which is only the earlier aspect of 1st stage labour, be classified as a continuum consisting of normal latent phase, prolonged latent phase and false labour. By this type of classification, false labour is not a differential diagnosis but a continuum of prolonged latent phase. Based on the knowledge that latent phase of whatever classification is merely yet the earlier aspect of first stage labour, the management should be passive observation until transformation into active phase labour in the absence of any associated complication either before or during the observation. This is the best option to avoiding orevoking further problem from what is a normal occurrence

Barriers to the universal application of the portograph for labour managent: A review of the issues and proposed solution

The Partograph is a simple clinical tool for recording observation in first stage active phase labour aiming to alert staff who provide care in labour to deviation in labour progress as well as in the wellbeing of mother and baby. Due to the devise of the alert and action line and the protocol for the use of the Partograph, there is early alert to complications (alert line) and the eventual treatment (action line), is by the staff with the requisite skill in order to ensure good feto-maternal outcome. This principle of the Partograph has not been clearly understood. The main reason for this misunderstanding is poor knowledge of why and how the Partograph was created. This is why there are the debate and consequent lack of a consensus over several issues like the number of hours of separationbetween the alert and action lines; use of the alert and action line in a tertiary centre; the time for artificial rupture of fetal membrane and the time for commencement of oxytocin augmentation to correct slow labour. These debates which constitute the barriers are all unnecessary because the facts which should guide opinion are revealed by a revisit to the history of the Partograph which will help to establish the reasons for each actions and procedure for the use of the Partograph. Finally, poor knowledge of how to use the Partograph to conduct labour is the greatest barrier for now. It is concluded that removing the barrier is best by concerted training on how to use the Partograph to all staff cadre involved in labour management.Keywords: Reducing Barriers to the use of Partograph for labour care

Partograph as a tool for team work management of spontaneous labor

It is presently being debated whether the partograph is a useful tool for labor supervision and, if useful, where should the action line be located between 2, 3 or 4 h to improve the fetomaternal outcome. This review adduces facts to show that this debate is because there is a poor understanding of the essence and purpose of the partograph. The partograph is a form on which labor observations are recorded to provide an overview of labor, aiming to alert midwives and obstetricians to deviations in labor progress as well as maternal and fetal wellbeing. When deviations in labor progress are recognized early and corrected, complications are prevented and normal labor and delivery can occur. The earliest deviation in labor progress is slow labor progress, for which the partograph alert line is a prompt for early recognition by the midwives and other non‑obstetric staff. The intervention to correct the deviation is at the action line by the staff with the requisite skill. In the circumstance in which the partogram was produced, the action to correct the deviation in labor progress was after 4 h, represented by the 4‑h action line, but other workers have attempted with 2‑ and 3‑h action lines and have had equally good results. However, in all these, the action at the action line was instituted by the staff with the appropriate skill, irrespective of whether the action line was 2, 3 or 4 h. As long as the action at the action line is by the staff with the requisite training, the deviation in labor progress will be corrected by either medical or surgical means irrespective of the action line location at 2, 3 or 4 h. In conclusion, the essence and purpose of the partograph is to ensure that labor progress is monitored to identify slow labor by the alert line but appropriate treatment must begin at the action line by the staff with the cognate skill, whether at 2, 3 or 4 h. The appropriateness of the intervention at the action line is the determinant of the outcome and not the delay.Nigerian Journal of Clinical Practice • Jan-Mar 2012 • Vol 15 • Issue

Active phase slow labour management: a review of the evolutionary history of the 2 hours and 4 hours oxytocin augmentation treatment

Context: Currently, slow labour is treated with oxytocin augmentation after delay of either 4 hours or 2 hours but there is debate as to whether the 2 hours or 4 hours delay is better to adopt especially for tertiary centre labour ward. Randomized controlled studies which have been conducted to resolve this issue have yielded conflicting reports because the studies used as primary outcome measures caesarean section rate or mode of delivery and perinatal outcome which are also affected by other confounding variables not related to the oxytocin augmentation. The debate as to which is better between the 4 hours and 2 hours delay before augmentation is still on.Objective: In order to identify the appropriate primary outcome measure to assess the 4 hours and 2 hours delay before augmentation, a historical review has been undertaken of the evolution of the 4 hours and 2 hours delay in order to identify the aim of treatment of the slow labour progress in active phase. This is to reveal what dependable primary outcome measure that can be used to assess which of 4 hours or 2 hours can better prevent prolonged labour which is the original aim of treating the slow labour with oxytocin augmentation. This is the way to end the debate.Sources of materials used: Information was obtained from Journals, medline, W.H.O. publications, Cochrane database systematic reviews and reputable textbooks using publications from 1969 to 2009.Materials: In active management of labour, it is the aim to prevent prolonged labour through a strategy to identify slow labour progress and institute immediate oxytocin augmentation hence the need for hourly vagina examination in the original concept by O'Driscoll and associates. Because this regimen required a large compliment of persons with good obstetric knowledge and materials, implementation was difficult hence there were modifications. This was first by Phillpott who designed oxytocin augmentation after 4 hours delay and later 2 hours and 3 hours by otherworkers before oxytocin augmentation when slow labour occurred. In spite of these delay the results were comparable to what O'Driscoll obtained with immediate augmentation and hourly vagina examinations. Presently,oxytocin augmentation is often after 4 hours or 2 hours delay after slow labour occurs. In a bide to know the better option, between 4 hours and 2 hours of delay, there have been randomized controlled studies in which the primary outcome measures assessed, were caesarean section rate or mode of delivery and perinatal outcome with conflicting results. The conflicting report is because mode of delivery and perinatal outcome following treatment of slow labour with oxytocin augmentation, is dependent more on the cause of the slow labour and state of the feto-placenta function before the augmentation. Hence, mode of delivery and perinatal outcome are not dependable outcome measures to assess which is the better option of 4 hours and 2 hours delay before augmentation. Since the aim of treating slow labour progress, is to restore progress to the normal 1cm per hours, cervical dilation rate, the appropriate outcome measure to assess in any comparative studies of the 4 hours and 2 hours are cervical dilation rate, duration of labour and reduction of prolonged labour rate.Conclusion: It is concluded that the appropriate outcome measure to assess randomized comparative studies of 4 hours and 2 hours delay before oxytocin augmentation, is cervical dilation rate, duration of labour and reduction of prolonged labour rate. This will produce reproducible results and help identify whether 4 hours or 2 hours delay before augmentation contribute more to preventing prolonged labour