Intra- and interobserver reproducibility of pelvic ultrasound for the detection and measurement of endometriotic lesions

STUDY QUESTION: What is the interobserver and intraobserver reproducibility of pelvic ultrasound for the detection of endometriotic lesions? SUMMARY ANSWER: Pelvic ultrasound is highly reproducible for the detection of pelvic endometriotic lesions. WHAT IS KNOWN ALREADY: Transvaginal ultrasound (TVS) has been widely adopted as the first-line assessment for the diagnosis and assessment of pelvic endometriosis. Severity of endometriosis as assessed by ultrasound has been shown to have good concordance with laparoscopy (kappa 0.79). The reproducibility of TVS for assessment of ovarian mobility and pouch of Douglas obliteration using the 'sliding sign' has already been described in the literature. However, there is no available data in the literature to demonstrate the intraobserver repeatability of measurements for endometriotic cysts and nodules. STUDY DESIGN SIZE DURATION: This was a prospective observational cross-sectional study conducted over a period of 12 months. We included 50 consecutive women who were all examined by two operators (A and B) during their clinic attendance. PARTICIPANTS/MATERIALS SETTING METHODS: The study was carried out in a specialist endometriosis centre. We included all consecutive women who had ultrasound scans performed independently by two experienced operators during the same visit to the clinic. The outcomes of interest were the inter- and intraobserver reproducibility for the detection of endometriotic lesions. We also assessed repeatability of the measurements of lesion size. MAIN RESULTS AND THE ROLE OF CHANCE: There was a good level of agreement between operator A and operator B in detecting the presence of pelvic endometriotic lesions (k = 0.72). There was a very good level of agreement between operators in identifying endometriotic cysts (k = 0.88) and a good level of agreement in identifying endometriotic nodules (k = 0.61). The inter- and intraobserver repeatability of measuring endometriotic cysts was excellent (intra-class correlation (ICC) ≥ 0.98). There was good interobserver measurement repeatability for bowel nodules (ICC 0.88), but the results for nodules in the posterior compartment were poor (ICC 0.41). The intraobserver repeatability for nodule size measurements was good for both operators (ICC ≥0.86). LIMITATIONS REASONS FOR CAUTION: Within this cohort, there was insufficient data to perform a separate analysis for nodule size in the anterior compartment. All examinations were performed within a specialised unit with a high prevalence of deep endometriosis. Our findings may not apply to operators without intensive ultrasound training in the diagnosis of pelvic endometriosis. WIDER IMPLICATIONS OF THE FINDINGS: These findings are important because ultrasound has been widely accepted as the first-line investigation for the diagnosis of pelvic endometriosis, which often determines the need for future investigations and treatment. The detection and measurement of bowel nodules is essential for anticipation of surgical risk and planning surgical excision. STUDY FUNDING/COMPETING INTERESTS: The authors have no conflict of interest. No funding was obtained for this work

Fast-track pathway for elective caesarean section: a quality improvement initiative to promote day 1 discharge.

Enhanced recovery after surgery (ERAS) aims to improve perioperative care, hasten recovery to the normal physiological state and shorten length of stay (LoS). There is evidence that ERAS programmes following elective caesarean section (ELCS) confer benefit through faster return to physiological state and reduced LoS for mother and baby. Baseline audit of ELCS in 2013 revealed a mean LoS of 3 days. We piloted an ERAS discharge pathway promoting day 2 discharge, which rose from 5.0% to 40.2%. 19.2% of women went home on day 1. Many women fed back that they would prefer day 1 discharge. We hypothesised that a day 1 discharge pathway for low-risk women could benefit both women and services at our maternity unit. From October 2015, we developed a 'fast-track pathway' (FTP) using a Plan-Do-Study-Act approach. Between October 2015 and April 2016, we prospectively audited clinical outcomes, LoS and maternal satisfaction from all women placed on the FTP. We held regular multidisciplinary team meetings to allow contemporaneous analysis. Satisfaction was analysed by Likert scale at postoperative surveys. Women were identified in antenatal clinic after meeting predefined low-risk criteria. 27.3% of women (n=131/479) delivering by ELCS entered the FTP. 76.2% of women on the FTP were discharged on day 1. Mean LoS fell to 1.31 days. 94.2% of women who established breast feeding at day 1 were still breast feeding at 7 days. Overall satisfaction at day 7 was 4.71 on a 5-point Likert scale. 73.1% of women reported good pain control. Additional financial savings are estimated at £99 886 annually. There were no related cases of readmission. Day 1 discharge after ELCS is safe and acceptable in carefully selected, low-risk women and has high satisfaction. There may be resultant financial savings and improved flow through a maternity unit with no detected adverse effect on breast feeding, maternal morbidity or postnatal readmissions

An assessment of the torrefaction of North American pine and life cycle greenhouse gas emissions

Bioenergy is increasingly being used to meet EU objectives for renewable energy generation and reducing greenhouse gas (GHG) emissions. Problems with using biomass however include high moisture contents, lower calorific value and poor grindability when compared to fossil fuels. Torrefaction is a pre-treatment process that aims to address these issues. In this paper four torrefaction treatments of pine were performed and a mass-energy balance calculated. Using experimental data, a pellet production supply chain incorporating torrefaction was modelled and compared to an existing wood pellet system to determine life-cycle GHG emissions. Two utility fuels, wood chips and natural gas, were considered to provide process heat in addition to volatile gases released during torrefaction (torgas). Experimental results show that torrefaction reduces the moisture content and increases the calorific value of the fuels. Increasing torrefaction temperature and residence time results in lower mass and energy yields. GHG emissions reduce with increasing torrefaction severity. Emissions from drying &amp; torrefaction and shipping are the highest GHG contributors to the supply chain. All 4 torrefaction conditions assessed outperformed traditional wood pellet supply chain emissions but more land is required which increases with temperature and residence time. Sensitivity analysis results show that emissions increase significantly where natural gas is used for utility fuel and no torgas is utilised.</p

Twin Binaries: Studies of Stability, Mass Transfer, and Coalescence

Motivated by suggestions that binaries with almost equal-mass components ("twins") play an important role in the formation of double neutron stars and may be rather abundant among binaries, we study the stability of synchronized close and contact binaries with identical components in circular orbits. In particular, we investigate the dependency of the innermost stable circular orbit on the core mass, and we study the coalescence of the binary that occurs at smaller separations. For twin binaries composed of convective main-sequence stars, subgiants, or giants with low mass cores (M_c <~0.15M, where M is the mass of a component), a secular instability is reached during the contact phase, accompanied by a dynamical mass transfer instability at the same or at a slightly smaller orbital separation. Binaries that come inside this instability limit transfer mass gradually from one component to the other and then coalesce quickly as mass is lost through the outer Lagrangian points. For twin giant binaries with moderate to massive cores (M_c >~0.15M), we find that stable contact configurations exist at all separations down to the Roche limit, when mass shedding through the outer Lagrangian points triggers a coalescence of the envelopes and leaves the cores orbiting in a central tight binary. In addition to the formation of binary neutron stars, we also discuss the implications of our results for the production of planetary nebulae with double degenerate central binaries.Comment: 17 pages, accepted to ApJ, final version includes discussion of planetary nebulae with central binaries and a new figure about shock heating, visualizations at http://webpub.allegheny.edu/employee/j/jalombar/movies

Search for Flavoured Multiquarks in a Simple Bag Model

We use a bag model to study flavoured mesonic $(Qq\bar q\bar q)$ and baryonic $({\overline Q}qqqq)$ states, where one heavy quark $Q$ is associated with light quarks or antiquarks, and search for possible stable multiquarks. No bound state is found. However some states lie not too high above their dissociation threshold, suggesting the possibility of resonances, or perhaps bound states in improved models.Comment: REVTEX, VERSION 3.

Gupta-Bleuler quantization for minimally coupled scalar fields in de Sitter space

We present in this paper a fully covariant quantization of the minimally-coupled massless field on de Sitter space. We thus obtain a formalism free of any infrared (e.g logarithmic) divergence. Our method is based on a rigorous group theoretical approach combined with a suitable adaptation (Krein spaces) of the Wightman-G\"{a}rding axiomatic for massless fields (Gupta-Bleuler scheme). We make explicit the correspondence between unitary irreducible representations of the de Sitter group and the field theory on de Sitter space-time. The minimally-coupled massless field is associated with a representation which is the lowest term of the discrete series of unitary representations of the de Sitter group. In spite of the presence of negative norm modes in the theory, no negative energy can be measured: expressions as \le n_{k_1}n_{k_2}...|T_{00}|n_{k_1}n_{k_2}...\re are always positive.Comment: 20 pages, appear in class. quantum gra

Comprehension as social and intellectual practice: Rebuilding curriculum in low socioeconomic and cultural minority schools

This article reframes the concept of comprehension as a social and intellectual practice. It reviews current approaches to reading instruction for linguistically and culturally diverse and low socioeconomic students, noting an emphasis on comprehension as autonomous skills. The Four Resources model (Freebody &amp; Luke, 1990) is used to make the case for the integration of comprehension instruction with an emphasis on student cultural and community knowledge, and substantive intellectual and sociocultural content in elementary school curricula. Illustrations are drawn from research underway on the teaching of literacy in primary schools in low SES communities

Case Report: A Truck Driver with Pelvic Pain

Extraskeletal myxoid chondrosarcoma (EMC) is a relatively rare soft tissue malignancy, originally described in the 1950s and characterized as a distinct entity from chondrosarcoma of the bone in the 1970s. These tumors most commonly originate in the proximal extremities, and their occurrence in the genitourinary tract is exceedingly rare, with few case reports citing origination in its component organs. We present a clinical case report of an EMC originating from the base of the penis with significant local involvement of the bony pelvis

Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised PSUMMIT 2 trial

Objective: Assess ustekinumab efficacy (week 24/week 52) and safety (week 16/week 24/week 60) in patients with active psoriatic arthritis (PsA) despite treatment with conventional and/or biological anti-tumour necrosis factor (TNF) agents. Methods: In this phase 3, multicentre, placebo-controlled trial, 312 adults with active PsA were randomised (stratified by site, weight (&#8804;100 kg/&#62;100 kg), methotrexate use) to ustekinumab 45 mg or 90 mg at week 0, week 4, q12 weeks or placebo at week 0, week 4, week 16 and crossover to ustekinumab 45 mg at week 24, week 28 and week 40. At week 16, patients with &#60;5% improvement in tender/swollen joint counts entered blinded early escape (placebo→45 mg, 45 mg→90 mg, 90 mg→90 mg). The primary endpoint was &#8805;20% improvement in American College of Rheumatology (ACR20) criteria at week 24. Secondary endpoints included week 24 Health Assessment Questionnaire-Disability Index (HAQ-DI) improvement, ACR50, ACR70 and &#8805;75% improvement in Psoriasis Area and Severity Index (PASI75). Efficacy was assessed in all patients, anti-TNF-naïve (n=132) patients and anti-TNF-experienced (n=180) patients. Results: More ustekinumab-treated (43.8% combined) than placebo-treated (20.2%) patients achieved ACR20 at week 24 (p&#60;0.001). Significant treatment differences were observed for week 24 HAQ-DI improvement (p&#60;0.001), ACR50 (p&#8804;0.05) and PASI75 (p&#60;0.001); all benefits were sustained through week 52. Among patients previously treated with &#8805;1 TNF inhibitor, sustained ustekinumab efficacy was also observed (week 24 combined vs placebo: ACR20 35.6% vs 14.5%, PASI75 47.1% vs 2.0%, median HAQ-DI change −0.13 vs 0.0; week 52 ustekinumab-treated: ACR20 38.9%, PASI75 43.4%, median HAQ-DI change −0.13). No unexpected adverse events were observed through week 60. Conclusions: The interleukin-12/23 inhibitor ustekinumab (45/90 mg q12 weeks) yielded significant and sustained improvements in PsA signs/symptoms in a diverse population of patients with active PsA, including anti-TNF-experienced PsA patients