ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol

Background: There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece). Methods: Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8–18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality. Discussion: The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries. Trial registration: NCT 04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greec

The contribution of decision making methodologies in increasing the diagnostic accuracy of endometrial cytology

Aim: Objective of this study is to investigate the potential of a computerized system ofclassification and regression trees (CARTs) for the discrimination of benign frommalignant endometrial nuclei and lesions.Methods: 228 histologically confirmed liquid based cytological smears were collected,specifically: 117 benign cases, 66 malignant cases, 37 hyperplasias without atypiaand 8 cases of hyperplasia with atypia.From each case we measured about 100 nuclei using an image analysis system, intotal we collected 22.783 nuclei and we extracted nuclear morphometric featuresusing a custom image analysis system. Initially we performed feature selection andsubsequently we applied a logistic regression model that classified each nucleus asbenign or malignant. Based on the results of nucleus classification process weconstructed an algorithm to discriminate endometrium cases as benign or malignant.The nuclei from 50% of the cases (the training set) were used to construct a CARTmodel that was used for knowledge extraction. The nuclei from the remaining cases(test set) were used to evaluate the stability and performance of the CART onunknown data. Based on the results of the CART for nuclei classification we proposedtwo classification methods to discriminate cases as benign or malignant.Results: The logistic regression system had an overall accuracy for the classificationof endometrial nuclei equal to 83.02%, specificity 85.09% and sensitivity 77.01%. Forthe case classification the overall accuracy was 92.98%, specificity 92.86% andsensitivity 93.24%.The CART model had an overall accuracy for the classification of endometrial nuclei equal to 85%, specificity 90.68% and sensitivity 72.05%. Both methods for cases classification had similar performance: overall accuracy in the range 94-95%, specificity 95% and sensitivity 91-94%.Conclusion: The proposed computerized system can be applied for the classification of endometrial nuclei and lesions as outperformed the standard cytological diagnosis. This study highlights interesting diagnostic features of endometrial nuclear morphology and the proposed method can be a useful tool in the everyday practice of the cytological laboratory.Σκοπός: Στόχος της παρούσας μελέτης είναι να διερευνήσει τις δυνατότητες μεθοδολογιών λήψης απόφασης, όπως η λογιστική παλινδρόμηση και τα δένδρα ταξινόμησης (CARTs) στη διάκριση των καλοήθων από κακοήθων αλλοιώσεων του ενδομητρίου.Υλικό - Μέθοδοι: Χρησιμοποιήθηκαν 228 κυτταρολογικά επιχρίσματα ενδομητρίου με ιστολογική επιβεβαίωση της διάγνωσης, και συγκεκριμένα: 117 καλοήθεις περιπτώσεις, 66 κακοήθεις, 37 υπερπλασίες χωρίς ατυπία και 8 περιπτώσεις υπερπλασίας με ατυπία. Από κάθε περίπτωση μετρήσαμε περίπου 100 πυρήνες χρησιμοποιώντας ένα σύστημα ανάλυσης εικόνας και συνολικά συλλέξαμε 22.783 πυρήνες και εξάγαμε μορφομετρικά πυρηνικά χαρακτηριστικά, χρησιμοποιώντας ένα σύστημα ανάλυσης προσαρμοσμένης εικόνας. Αρχικά πραγματοποιήθηκε επιλογή χαρακτηριστικών και στη συνέχεια εφαρμόσαμε ένα μοντέλο λογιστικής παλινδρόμησης που ταξινομούσε κάθε πυρήνα ως καλοήθη ή κακοήθη. Με βάση τα αποτελέσματα της διαδικασίας ταξινόμησης πυρήνα κατασκευάσαμε έναν αλγόριθμο για να τεθεί η τελική διάγνωση καλοήθειας ή κακοήθειας.Για τα δένδρα ταξινόμησης χρησιμοποιήθηκαν πυρήνες από το 50% των περιπτώσεων (σύνολο εκπαίδευσης) για να κατασκευαστεί ένα μοντέλο δένδρο, το οποίο χρησιμοποιήθηκε για την παροχή γνώσης. Οι πυρήνες από τις υπόλοιπες περιπτώσεις (σετ δοκιμής) χρησιμοποιήθηκαν για να αξιολογηθεί η σταθερότητα και η απόδοση του CART σε άγνωστα δεδομένα. Με βάση τα αποτελέσματα του CART γίνεται επίσης η διάκριση των περιπτώσεων σε καλοήθεις ή κακοήθεις.Αποτελέσματα: Το σύστημα λογιστικής παλινδρόμησης είχε μια συνολική ακρίβεια για την κατάταξη των πυρήνων του ενδομητρίου 83.02%, 85.09% ειδικότητα και ευαισθησία 77.01%. Για την κατάταξη περιπτώσεων, η συνολική ακρίβεια ήταν 92.98%, 92.86% ειδικότητα και ευαισθησία 93.24%.Το μοντέλο CART είχε μια συνολική ακρίβεια για την κατάταξη των πυρήνων του ενδομητρίου 85%, ειδικότητα 90.68% και 72.05% ευαισθησία. Και οι δύο μέθοδοι ταξινόμησης για τις περιπτώσεις είχαν παρόμοια απόδοση: συνολική ακρίβεια της τάξεως 94-95%, ειδικότητα 95% και ευαισθησία 91-94%.Συμπέρασμα: Τα προτεινόμενα συστήματα πληροφορικής μπορεί να εφαρμοστούν για την κατάταξη των πυρήνων του ενδομητρίου και καλοήθων ή κακόηθων περιπτώσεων. Η μελέτη αυτή αναδεικνύει ενδιαφέροντα διαγνωστικά χαρακτηριστικά του ενδομητρίου πυρηνική μορφολογία και η προτεινόμενη μέθοδος μπορεί να αποτελέσει χρήσιμο εργαλείο στην καθημερινή πρακτική του εργαστηρίου κυτταρολογικών

A new tool to assess amnestic mild cognitive impairment in Turkish older adults: virtual supermarket (VSM)

The purpose of this study was to investigate cognitive functioning by administering the Virtual Supermarket (VSM) test in patients with amnestic mild cognitive impairment (aMCI, N = 37) and age and education-matched healthy controls (HCs, N = 52). An extensive neuropsychological test battery and the VSM were administered to all participants. The aMCI group exhibited lower performance and required more time to complete the VSM compared to HCs. Also, aMCI-Multiple Domain (aMCI-MD) patients performed worse in the "Correct Types", "Correct Quantities", "Bought Unlisted", "Correct Money" variables compared to HCs. Moreover, aMCI-SD patients displayed lower performance in "Bought Unlisted" and "Correct Money" variables compared to HCs. The VSM variables correlated with established neuropsychological test scores. The VSM test was found to discriminate between aMCI and HCs with a correct classification rate (CCR) of 81%. This is a preliminary study showing that the VSM is a valid, brief and user-friendly test.

Uterine sparing management in patients with endometrial cancer: a narrative literature review

Endometrial cancer is the most common malignancy of the female genital tract. Approximately 25% of cases occur in premenopausal women, and up to 5% of cases occur in women who are younger than 40 years old. The survival rate in these cases is 99%; therefore, uterine-sparing management could be considered under strict criteria selection and the strong desire of the woman to preserve uterus and fertility. Diagnosis should be performed after a hysteroscopic biopsy instead of dilatation and curettage. The highest remission rate was achieved after combining a hysteroscopic resection with hormonal therapy compared to single hormonal treatment. The most common regiments are the following progestins: megestrol acetate (MA) and medroxyprogesterone acetate (MPA) taken orally with a daily dosage of 160 mg–320 mg for MA and 250 mg–600 mg for MP. Evaluations at three and six months could be performed by office endometrial biopsy and/or hysteroscopic directed biopsy especially in the presence of levonorgestrel intrauterine system, and in cases of remission, either a pregnancy attempt or maintenance therapy should be considered. After childbearing, hysterectomy with bilateral salpingo–oophorectomy is recommended, whereas ovarian preservation could be considered depending on the patient’s age and whether they fulfil the strict criteria selection

A Virtual Reality-Based Screening Test for Cognitive Impairment in Small Vessel Disease

Background: There is a need for newpractical tools to assess the cognitive impairment of small vessel disease (SVD) patients in the clinic

Acute lung injury in preterm fetuses and neonates: mechanisms and molecular pathways

Acute lung injury (ALI) results in high morbidity and mortality among preterm neonates and efforts have therefore been devoted to both antenatal and postnatal prevention of the disease. ALI is the result of an inflammatory response which is triggered by a variety of different mechanisms. It mostly affects the fetal lung and, in particular, causes damage to the integrity of the lung’s alveolar-capillary unit while weakening its cellular linings. Chemotactic activity and inflammatory products, such as proinflammatory cytokines TNF-alpha, IL-1, IL-6, IL-11, VEGF, TGF-alpha and TGF-beta, provoke serious damage to the capillary endothelium and the alveolar epithelium, resulting in hyaline membrane formation and leakage of protein-rich edema fluid into the alveoli. Chorioamnionitis plays a major part in triggering fetal lung inflammation, while mechanical ventilation, the application of which is frequently necessary in preterm neonates, also causes ALI by inducing proinflammatory cytokines. Many different ventilation-strategies have been developed in order to reduce potential lung injury. Furthermore, tissue injury may occur as a result of injurious oxygen by-products (Reactive Oxygen Species, ROS), secondary to hyperoxia. Knowledge of the inflammatory pathways that connect intra-amniotic inflammation and ALI can lead to the formulation of novel interventional procedures. Future research should concentrate on the pathophysiology of ALI in preterm neonates and on possible pharmaceutical interventions targeting prevention and/or resolution of ALI

Perinatal Inflammation: Could Partial Blocking of Cell Adhesion Molecule Function Be a Solution?

In spite of the great advances made in recent years in prenatal and perinatal medicine, inflammation can still frequently result in injury to vital organs and often constitutes a major cause of morbidity. It is today well established that in neonates—though vulnerability to infection among neonates is triggered by functional impairments in leukocyte adhesion—the decreased expression of cell adhesion molecules also decreases the inflammatory response. It is also clear that the cell adhesion molecules, namely, the integrins, selectins, and the immunoglobulin (Ig) gene super family, all play a crucial role in the inflammatory cascade. Thus, by consolidating our knowledge concerning the actions of these vital cell adhesion molecules during the prenatal period as well as regarding the genetic deficiencies of these molecules, notably leukocyte adhesion deficiency (LAD) I, II, and III, which can provoke severe clinical symptoms throughout the first year of life, it is anticipated that intervention involving blocking the function of cell adhesion molecules in neonatal leukocytes has the potential to constitute an effective therapeutic approach for inflammation. A promising perspective is the potential use of antibody therapy in preterm and term infants with perinatal inflammation and infection focusing on cases in which LAD is involved, while a further important scientific advance related to this issue could be the combination of small peptides aimed at the inhibition of cellular adhesion