Non-haemorrhagic causes of obstetrical intensive care unit admissions in tertiary care setting

Background: Management of critically ill obstetric patients involve intensive monitoring in intensive care unit. In present scenario there are significant number of obstetric patients with sepsis, tropical diseases and medical illness that require ICU care. The aim of this study was to evaluate in more detail the non-haemorrhagic causes of obstetric ICU admissions and to identify and adopt high risk strategies as prime learning objective.Methods: It is a prospective ongoing study conducted in 50 patients in SGRDUHS, Amritsar from December 2016 to October 2019, who were admitted in obstetric ICU, out of them 30 cases were attributed to non-haemorrhagic obstetric causes. All demographic parameters along with gestational age, diagnosis on admission, intervention done prior to shift to ICU and details of treatment given in ICU were evaluated. Patient outcome, review of mortality and area of improvement were also noted.Results: Majority of the patient (70.1%) were admitted in 3rd trimester. Obstetric sepsis (13.33%), infective diseases (16.66%), tropical conditions (16.66%), medical disorders (26.66%) and hypertensive disorders (26.66%) were the major causes of admission to obstetric ICU. There were 33.3% mortalities observed in present study and 40% were due to respiratory failure. In ICU mechanical ventilation was done in 63.3% cases and blood products were given in 33.3% of patients.Conclusions: A multidisciplinary approach is ideal to handle non-haemorrhagic situations especially related to medical disorders and tropical diseases. Review of the ICU admissions and periodic audit can improve management of morbidities as well as reduce maternal mortalities

Adenomyosis: correlating clinical suspicion with histopathological diagnosis in a retrospective study

Background: Adenomyosis and leiomyoma are the common causes of abnormal uterine bleeding (AUB). In this study it is aimed to evaluate the correlation of clinical and histopathological examination (HPE) of these entities leading to abnormal uterine bleeding.Methods: This retrospective study was carried out on hysterectomy specimens of subjects who presented themselves in the department of obstetrics and gynaecology of Sri Guru Ram Das Institute of medical sciences and research, Amritsar with chief complaints of AUB not responding to conservative treatment.Results: A total of 100 women with clinical diagnosis of AUB in which hysterectomies were performed, leiomyoma was found in 42% cases, adenomyosis in 22% cases. The most frequent combination of diagnosis was leiomyoma and adenomyosis i.e. 26%. In 9% cases chronic cervicitis and ovarian cyst were detected. In one case endometrial malignancy was found.Conclusions: Though adenomyosis and leiomyoma are clinically diagnosed along with other pathological conditions of the reproductive organs but their confirmation is still to be relied upon HPE; a most important investigation

HYSTEROSALPINGOGRAPHY: TECHNIQUE AND APPLICATIONS (VIEW)

Hysterosalpingography (HSG) is the radiographic evaluation of the uterine cavity and fallopian tubes after the administration of a radio-opaque medium through the cervical canal. The first HSG was performed in 1910 and was considered to be the first special radio¬logic procedure. A properly performed HSG can de¬tect the contour of the uterine cavity and the width of the cervical canal. Further contrast medium injection will outline the cornua isthmic and ampullary portions of the tubes, and will show the degree of spillage. If a properly performed HSG shows no uterine cavity abnormality, it is very unlikely that other modalities would do so. Although this procedure is considered diagnostic, there may also be a possible therapeutic benefit from the flushing effect. Indications and Contraindications HSG is used predominantly in the evaluation of in-fertility. Despite the arrival of newer imaging modalities, HSG still remains the best procedure to image the fallopi¬an tubes. Although evaluating feminine infertility, with or without the presence of repeated miscarriages, is the main indication for this method, it can also be used in other cas-es, such as pain in the pelvis tract, congenital or anatomic abnormalities, anomalies of the menstrual cycle, and ab-normal menses. Also, it is sometimes used as a preoper-ative control for women who are about to have uterine or tubal surgery. Soares and coworkers showed that HSG had a sensitivity of 58% and a positive-predictive value of 28.6% for polypoid lesions, and a sensitivity of 0% for endometrial hyperplasia. The same study showed HSG to have a sensitivity of 44.4% for uterine malformations, and a sensitivity of 75% for the detection of intrauterine adhesions. The main contraindication of the examination is possible pregnancy. This contraindication can be avoid¬ed by performing the examination before the ovulation phase, between the 7th to 10th day of the menstrual cycle. Because of the scattering risk, the examination should be avoided when there is active intrapelvic inflammation. Another contraindication is vaginal or uterine bleeding because of the risk of unrestrained bleeding, which could lead to transfusion or surgical recovery procedures. Fi¬nally, the examination should not be performed in cases of severe cardiac or renal deficiency, or in cases of recent uterine or tubal surgery. Technique Patient Preparation The procedure is performed in the first half of the menstrual cycle following cessation of bleeding. The endometrium is thin during this proliferative phase, which facilitates better image interpretation and should also ensure that there is no pregnancy. The patient is asked to refrain from unprotected sexual intercourse from the date of her period until after the investigation to be certain there is no risk of pregnancy. Examination in the second half of the cycle is avoided because the thickened secretory-phase endometrium increases the risk of venous intravasation and may cause a false-pos¬itive diagnosis of cornual occlusion. Antibiotics might be required 1 day before and for a few days after the examination if previous inflamma¬tions are present in the patient’s clinical history. Antibiotics are required after the examination when the maneuvers are fairly sanguineous or if the fallopian tubes present a certain degree of dilation. The suggest¬ed antibiotic regimen is metronidazole 1 g rectally at the time of the procedure, plus doxycycline 100 mg twice daily for 7 days.Steroid (prednisolone) premed¬ication is prescribed in asthmatics when intravenous contrast is used; there-fore, it is reasonable to do the same for HSG because intravasation is also possible from this procedure. Catheterization Technique For the catheterization technique, the patient is placed on the fluoroscopic machine in a gynecologic examination position. After cleaning the external gen¬ital area with antiseptic solution, the vagina is dilated by a gynecologic dilator. The cervix is localized and cleansed with iodine solution. Afterward, the uterine cervix is straightened by one (at the 12 o’clock posi¬tion) or two (at the 9 and 3 o’clock positions) surgi¬cal forceps exercising a degree of pulling. Next, the outside uterine cervix ostium is catheterized. The catheterization can be performed in two ways. In the authors’ country, a salpinographer with a bell-shaped end (diameter depends on the case) is pushed through the vagina and fits in the external uterine cervix osti¬um. In the second technique, the salpingographer has a plastic cup-shaped end that is fitted to the external uterine cervix ostium, creating a void phenomenon. In both techniques, there is a syringe with iodinated hydrosoluble contrast medium at the other end of the salpingographer. The vagina dilator is taken off after catheterization of the external uteri cervix ostium and before administration of the contrast medium. Contrast Media In the past, oil-soluble contrast media were mainly used. Today, we use all available iodinated hydrosol¬uble contrast media. According to international liter¬ature, the use of oil-soluble contrast media increases the pregnancy rate and contributes to a decrease in conception time after the salpingography is performed. However, Spring and coworkers found that there is no evidence that the choice of the contrast material affects the rate of term pregnancy. Moreover, they reported that oil-soluble contrast media may promote granulo¬matous inflammation in the presence of obstructed or inflamed fallopian tubes. Radiological Views One conventional radiograph of the pelvis (on a 24¬30 cm radiologic film) is necessary before the contrast medium is administrated into the uterine cavity so that possible intrapyelic masses or calcifications will not complicate interpretation of the images. A metallic marker is placed over one side of the pelvis to indicate the right or left side of the patient. Next, the examina¬tion is performed under fluoroscopic control so that ra¬diographs can be taken during the filling of the uterine cavity (usually 2-3 cm of contrast medium is sufficient) and again during the filling of the fallopian tubes. Final¬ly, after the removal of the salpingographer, we radio¬graphically check the presence of contrast medium in the peritoneal cavity. The total amount of injected con¬trast medium should not exceed 10 mL. Additional spot radiographs are obtained to document any abnormality that is seen. Before the first radiograph, we also fluoro- scopically check the reflux of the contrast medium. Complications The two most common complications of HSG are pain and infection. These and other complications and side effects are summarized below. • Uterine contractions and discomfort due to the introduction of contrast medium into the uterine cavi¬ty: The most common type of pain referenced is subab¬dominal colic caused by dilation of the uterine cavity. A more diffuse pain, caused by irritation of the peri¬toneum due to the contrast medium, has also been re¬ported. Pain can be minimized by slowly injecting the contrast medium and using isosmolar contrast agents. • Postprocedural infection: Spreading and gener-alization of intrapyelic inflammation may happen in cases of chronic inflammation and hydrosalpinges, or after severe uterine injury caused by the examination maneuver. • Vasovagal reaction: A possible reaction to ma-nipulation of the cervix or inflation of a conclusion balloon in the cervical canal. • Traumatic elevation of endometrium by the in¬serted cannula: A complication which does not cause significant consequences. • Uterine perforation and tubal rupture: These complications are very rare. • Venous or lymphatic intravasation of contrast me-dia: With a water-based contrast medium there is no ad-verse effect on the patient, but it can make interpretation of the image difficult. It occurs more commonly in the presence of fibroids or tubal obstruction. Extravasation of the contrast medium could occur if the contrast me¬dium is administered too quickly, if the endometrium is injured during the catheterization, or if the examination is performed during menstruation. Extravasation is also possible when common or special inflammations of the endometrium are present due to the intercourse rate be-tween the uterine vein and the ovarian veins. • Allergic reaction to contrast media: Such a reac¬tion is very uncommon with the use of the low-osmolar nonionic contrast agents currently available. • Radiation exposure to the ovaries: Exposure is minimal and can be reduced if the proper technique is utilized. Normal Findings On face radiographs, the uterine cavity has a nor¬mal trigonal shape and the apex of the triangle corre¬sponds to the isthmus, which is nearly 3.7 cm wide. The apex is pointed downwards and connected to the internal ostium of the cervix uteri, which is 2.5 cm in total length. The base of triangular uterine cavity is the fundus, which can be concave, flattened, or slightly convex. On both sides of its base, in the area of the lateral horns, the two fallopian tubes are drowned. The fallopian tubes are separated into three segments: isth¬mus (attached to the uterus, not imaged in several cas¬es), ampullary (in the middle, the longest and widest segment), and bell-shaped (to the distal end). There are two ostiums: the internal or uterine, and the external or abdominal. From the abdominal ostium, the con¬trast medium disperses and diffuses into the peritone¬al cavity. Remaining contrast medium in the furrows of the peritoneum can be observed up to 3 hours after administration. Very often, the contrast medium in the rectouterine pouch of the peritoneum (Douglas’ space) can demonstrate the profile of the coordinate ovary. Congenital Uterus Anomalies Congenital uterus anomalies are caused by incom¬plete junction of the paramesonephric ducts (Muller ducts), or Extravasations of the contrast medium. The true incidence and prevalence of mullerian duct anomalies are difficult to assess. Examination of different patient populations, nonstandardized clas¬sification systems, and differences in diagnostic data acquisition has resulted in widely disparate estimates, with a reported prevalence that ranges from 0.16 to 10%. As a result of selection bias, a prevalence of 8 to 10% has been reported in women being evaluated with HSG because of recurrent pregnancy loss. The overall data suggest that the prevalence both in women with normal fertility and in women with infertility is approximately 1%, and the prevalence in women with repeated pregnancy loss is approximately 3%. While the majority of women with mullerian duct anomalies have little problem conceiving, they have higher associated rates of spontaneous abortion, pre¬mature delivery, and abnormal fetal position and dys¬tocia at delivery. Most studies report an approximate frequency of 25% for associated reproductive prob¬lems, compared with 10% in the general population. Primary infertility in these women usually has an ex¬tra uterine cause and is not generally attributable to mullerian duct anomalies alone. Additionally, cervical incompetence has been reported to be associated with these anomalies. According to the American Society of Reproduc¬tive Medicine, there are seven different classes of mul¬lerian duct anomalies: Class I: Segmental agenesis or variable degrees of uterovaginal hypoplasia. The anomaly can be detected, because of the amenorrhea, before HSG is performed. Class II: Unicornuate uteri that represent partial or complete unilateral hypoplasia. In rare cases of degen-eration of the mesonephric duct, the uterine cavity ap¬pears monocular when imaged, placed right or left of the middle line. The unicornuate uterus contacts only the coordinate fallopian tube. Class III: Didelphys uterus. This is a rare abnor¬mality that results from complete nonfusion of the mullerian ducts, and includes the duplication of the uterine cavity, cervix neck, and vagina. Rarely, this uterus has a single vagina. Class IV: Bicornuate uterus that demonstrates incomplete fusion of the superior segments of the uterovaginal canal. The uterine cavity is divided in two; each half has a narrow-length shape and stands apart from the other. Class V: Septate uteri that represent partial or com¬plete nonresorption of the uterovaginal septum. Class VI: Arcuate uterus resulting from nearly complete resorption of the septum. Along with the pre¬vious anomaly, these are the most common congenital anomalies (50%) in cases detecting female infertility. Class VII: Anomalies that comprise sequelae of in utero diethyloestradiol exposure. Another congenital anomaly, caused by inadequate hormonic stimulation as a fetus, is small uterine cavi¬ty size with normal vaginal length. This is a common finding in cases of female infertility. Abnormal Findings Fibromyomas While fibromas are diagnosed by suprapubic ultra-sound, submucosa fibromyomas are imaged as smooth filling defects in the uterine cavity. Differential diagno¬sis must be made from endometrial polyps or possible pregnancy. Small intramural fibromyomas do not distort the endometrial cavity and are not visualized on HSG. Subserous fibromyomas can provoke smooth filling de-fects or smooth repression of the fallopian tubes only if they are located in the lateral walls of the uterus. Endometrial Polyps Endometrial polyps are focal overgrowths of the endometrium. They usually manifest as well-defined filling defects and are best seen during the early filling stage. Small polyps may be obscured when contrast material completely fills the uterine cavity and may be indistinguishable from a small submucosal myoma. Sonohysterography has become the preferred method of imaging endometrial polyps. Internal Endometriosis (Adenomyosis) Adenomyosis is caused by the presence of ectopic islets of active endometrium in the muscularis wall of the uterus. It is usually imaged as a pointed projection of 2 to 3 mm length, perpendicular to the uterine wall after contrast medium administration. Rarely, this is imaged as a sack-shaped projection filled by contrast medium, 4 mm to 1 cm in length. Differential diag¬nosis should include the hyperplasia of the endome¬trium and the entrance of the contrast medium in the myometrium or in the nutrient arteriole of submucosa fibromyomas. Uterine Cancer Uterine cancer manifests as an irregular filling de¬fect, but is rarely diagnosed by the HSG method. Intrauterine Adhesions Intrauterine adhesions are most commonly caused by endometrial trauma of curettage. They are also seen in patients with chronic endometriosis due to tubercu¬losis. Genital tuberculosis primary affects the fallopian tubes, and 50% of patients with tubal disease also have a uterine abnormality. Intrauterine adhesions manifest as irregular filling defects, most commonly as linear filling defects arising from one of the uterine walls. Hydrosalpinx HSG is the best method for visualizing and eval¬uating the fallopian tubes. Hydrosalpinx is a common finding that results from a previous inflammation of the fallopian tubes (salpingitis). This is usually the se¬quelae of distal tubal occlusion, leading to dilation of the proximal segment. The radiologic image shows a dilated lumen in one or more spots, and the contrast medium will not make its way to the peritoneal cavity Tuberculated Salpingitis This entity usually causes distant fallopian tube end obliteration. In extensive infections, multiple con¬strictions along the course of fallopian tube can form, resulting in areas of dilation and stenosis. Abnormal uterine and vaginal profiles are observed in cases of widespread infection. Salpingitis Isthmica Nodosa Salpingitis isthmica nodosa is a disease of un¬known etiology, characterized by multiple small out- pouchings or diverticula affecting one or both fallopian tubes. It is presumably caused by pelvic inflammatory disease or endometriosis and is associated with ectopic pregnancy and infertility. Nondrawing of the Fallopian Tubes This is the most common finding during the exam-ination and is usually caused by poor technique, spasm, or obliteration of the fallopian tube. Poor technique in¬cludes imperfect straightening of the external cervical ostium or an inadequate amount of contrast medium in the uterine cavity. The cornual portion of the fallopian tube is encased by the smooth muscle of the uterus and, if there is a spasm of the muscle during HSG, one or both tubes may not fill. Using radiography, tubal spasm cannot be distinguished from tubal occlusion. This could be avoided by progressive administration of the contrast medium or, when the spasm occurs, administration of a spasmolytic agent to relieve spasm, helping differentiate cornual spasm from true occlusion. Obliteration is usu¬ally caused by previous inflammation or uterine surgery and manifests as nonopacification or abrupt cutoff of the fallopian tube with no free intraperitoneal spillage. External Adhesions External adhesions occur secondary to previous inflammation or surgery, similar to the causes of tubal occlusion. Peritubal adhesions prevent contrast materi¬al from flowing freely around the bowel loops as seen in normal cases, and most commonly manifest as loc- ulation of the contrast material around the ampullary portion of the tube. Conclusion. HSG remains the front-line imaging modality in the investigation of infertility. It is an ac¬curate means of accessing the uterine cavity and tubal patency, but has a low sensitivity for the diagnosis of pelvic adhe¬sions, which is why it cannot replace laparoscopy. It requires knowledge of the female anatomy as well as skillful technique in order to avoid pitfalls and misin¬terpretations.Кафедра акушерства та гінекологі

Temporal changes in cardiovascular disease and infections in dialysis across a 22-year period:a nationwide study

Abstract Background Cardiovascular diseases (CVD) and infections are recognized as serious complications in patients with end stage kidney disease. However, little is known about the change over time in incidence of these complications. This study aimed to investigate temporal changes in CVD and infective diseases across more than two decades in chronic dialysis patients. Methods All patients that initiated peritoneal dialysis (PD) or hemodialysis (HD) between 1996 and 2017 were identified and followed until outcome (CVD, pneumonia, infective endocarditis (IE) or sepsis), recovery of kidney function, end of dialysis treatment, death or end of study (December 31st, 2017). The calendar time was divided into 5 periods with period 1 (1996–2000) being the reference period. Adjusted rate ratios were assessed using Poisson regression. Results In 4285 patients with PD (63.7% males) the median age increased across the calendar periods from 65 [57–73] in 1996–2000 to 69 [55–76] in 2014–2017, (p <  0.0001). In 9952 patients with HD (69.2% males), the overall median age was 71 [61–78] without any changes over time. Among PD, an overall non-significant decreasing trend in rate ratios (RR) of CVD was found, (p = 0,071). RR of pneumonia increased significantly throughout the calendar with an almost two-fold increase of the RR in 2014–2017 (RR 1.71; 95% CI 1.46–2.0), (p <  0.001), as compared to the reference period. The RR of IE decreased significantly until 2009 (RR 0.43; 95% CI 0.21–0.87), followed by a return to the reference level in 2010–2013 (RR 0.87; 95% CI 0.47–1.60 and 2014–2017 (RR 1.1; 95% CI 0.59–2.04). A highly significant (p <  0.001) increase in sepsis was revealed across the calendar periods with an almost 5-fold increase in 2014–2017 (RR 4.69 95% CI 3.69–5.96). In HD, the RR of CVD decreased significantly (p <  0.001) from 2006 to 2017 (RR 0.85; 95% CI 0.79–0.92). Compared to the reference period, the RR for pneumonia was high during all calendar periods (p <  0.05). The RR of IE was initially unchanged (p = 0.4) but increased in 2010–2013 (RR 2.02; 95% CI 1.43–2.85) and 2014–2017 (RR 3.39; 95% CI 2.42–4.75). No significant changes in sepsis were seen. Conclusion Across the two last decades the RR of CVD has shown a decreasing trend in HD and PD patients, while RR of pneumonia increased significantly, both in PD and in HD. Temporal trends of IE in HD, and particularly of sepsis in PD were upwards across the last decades

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016

Exploration of womanist issues in the poetry of Gwendolyn Brooks and Maya Angelou : a comparative analysis

This essay looks at the works of two African American female poets who have a different outlook and approach on writing about most issues. The language including tone, voice, rhythm, sensory engagement, and dialect is analyses to compare their approaches. Additionally, the essay also examines how the two poets handle some common African American and feminist literary themes

Simulation and Detection of LDDoS Attacks using Queuing Algorithms

This study aims at the evaluation of queuing algorithms using NS2 simulator. The recent LDDoS attacks cause more severe damage to the TCP based applications than the traditional DDoS attacks. The congestion participation rate (CPR) approach is used for detection and prevention of LDDoS attacks. Earlier approaches can only detect the LDDoS attacks. The CPR approach using queuing management algorithms shows better results than the DFT approach. The simulations are done using various parameters such as throughput, delay and bandwidth. Drop tail and red software are also compared using CPR approach; the better performance is given by RED approach using CPR. General Terms Comparison between normal TCP flow and LDDoS attack flow by using CPR approach using the three queuing management algorithms named REM, RED and DROPTAIL

Noisy Galvanic Vestibular Stimulation Combined With a Multisensory Balance Program in Older Adults With Moderate to High Fall Risk: Protocol for a Feasibility Study for a Randomized Controlled Trial

BackgroundReduced mobility and falls are common among older adults. Balance retraining programs are effective in reducing falls and in improving balance and mobility. Noisy galvanic vestibular stimulation is a low-level electrical stimulation used to reduce the threshold for the firing of vestibular neurons via a mechanism of stochastic resonance. ObjectiveThis study aims to determine the feasibility of using noisy galvanic vestibular stimulation to augment a balance training program for older adults at risk of falls. We hypothesize that noisy galvanic vestibular stimulation will enhance the effects of balance retraining in older adults at risk of falls MethodsIn this 3-armed randomized controlled trial, community dwelling older adults at risk of falling will be randomly assigned to a noisy galvanic vestibular stimulation plus balance program (noisy galvanic vestibular stimulation group), sham plus balance program (sham group), or a no treatment group (control). Participants will attend the exercise group twice a week for 8 weeks with assessment of balance and gait pretreatment, posttreatment, and at 3 months postintervention. Primary outcome measures include postural sway, measured by center of pressure velocity, area and root mean square, and gait parameters such as speed, step width, step variability, and double support time. Spatial memory will also be measured using the triangle completion task and the 4 Mountains Test. ResultsRecruitment began in November 2020. Data collection and analysis are expected to be completed by December 2022. ConclusionsThis study will evaluate the feasibility of using noisy galvanic vestibular stimulation alongside balance retraining in older adults at risk of falls and will inform the design of a fully powered randomized controlled trial. Trial RegistrationNew Zealand Clinical Trials Registry (ACTRN12620001172998); https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379944 International Registered Report Identifier (IRRID)DERR1-10.2196/3208