Clinical competence in performing and recognising a mediolateral episiotomy of protective angle and length: a systematic review

Objective: It is assumed that all doctors and midwives understand and apply evidence‐based principles in performing episiotomies in their everyday practice. However, remarkable discrepancies between even the most reputable literature sources in defining and describing the technique of performing mediolateral episiotomy (MLE) suggest that there is much ambiguity and confusion for both researchers and clinicians alike. Design: The systematic review protocol was written prior to starting the review and registered in the international prospective register of systematic reviews (PROSPERO/ID CRD42017070523) last updated on December 15, 2017. The review is reported using the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Methods: A database search was performed using: Medline, CINAHL, Scopus, Informit, the Cochrane Library and PubMed from database inception to 17 September 2017, with a final search on 10 February 2017. Studies were included if they examined clinicians' competency in performing an 'ideal' or 'correct' mediolateral episiotomy, as well as those studies that compared the performance of different professional roles. Studies usually defined an 'ideal' incision as one that met the criteria of an acceptable angle of incision from the midline, starting incision point distance from the midline and in terms of the length of the incision created. Results: While many of the studies included in this review were not of high quality (author self‐assessment) and had their own study criteria for a MLE, the literature suggests clinicians are generally unable to perform or simulate episiotomies within such standards. Overall, most of the literature reported doctors were performing more 'ideal', lateral and longer incisions compared to midwives; however, there were studies that found the opposite, showing statistically significant results in favour of midwives performing more protective episiotomies. There was no association between clinicians' participation in formal training courses and their ability to perform the 'ideal' incision, though one study did find an increased number of episiotomies performed under supervision improved clinicians competency. Conclusion: The obvious lack of understanding around defining and performing MLE for clinicians of various professional roles suggests the need to produce a uniform set of guidelines, and to develop a universal, low‐cost approach for teaching and performing the MLE technique in any clinical environment around the world

Effect of balloon angioplasty in femoropopliteal arteries assessed by intravascular ultrasound

Objective:To study the effects of balloon angioplasty (PTA) of the femoropopliteal artery with intravascular ultrasound (IVUS).Materials and methods:Corresponding IVUS cross-sections (n = 1033) obtained before and after PTA from 115 procedures were analysed. Vascular damage including plaque rupture, dissection and media rupture was assessed. Free lumen area (FLA), media-bounded area (MBA) and plaque area (PLA) were measured.Results:After PTA vascular damage was seen at the target site in 83 (72%) arteries: plaque rupture in 30 (26%), dissection in 66 (57%) and media rupture in 20 (17%) arteries. The FLA increased from 5.4 ± 3.4 mm2 to 14.1 ± 5.0 mm2 (p<0.001), MBA increased from 26.9 ± 10.0 mm2 to 32.9 ± 10.7 mm2 (p<0.001) and PLA decreased from 21.6 ± 8.5 mm2 to 18.8 ± 8.0 mm2 (p<0.001). The increase in MBA accounted for 68% of lumen gain. The frequency of vascular damage and the relative contribution of MBA increase and PLA decrease to luminal gain were not different in procedures with balloon diameter ≤ 5 mm and ≥ 6 mm.Conclusions:Vascular damage is common following PTA. Lumen gain is mainly due to vessel expansion and, to a lesser extent, to a decrease in plaque area

Femorodistal venous bypass evaluated with intravascular ultrasound

Objective:To evaluate the feasibility of intravascular ultrasound imaging during femorodistal venous bypass procedures to assess qualitative and quantitative parameters of the greater saphenous vein and to detect potential causes for (re)stenosis and/or occlusion.Methods:Intravascular ultrasound data obtained from 15 patients were reviewed and compared with angiographic data.Results:Intravascular ultrasound enabled differentiation between normal and thickened vein wall. Venous side-branches could be located. Intact valves could be differentiated from valves disrupted by valve cutting. Patent anastomoses could be distinguished from anastomoses with some degree of obstruction. Intravascular ultrasound imaging of the inflow and outflow tracts revealed obstructive lesions, not evidenced angiographically. Quantitative analysis revealed that the median normal vein wall thickness (tunica intima and tunica media) was 0.25 mm (range 0.17–0.40 mm). The distinct vein wall thickening encountered in three patients measured 0.82, 0.95 and 1.06 mm, respectively, and was associated with narrowing in two patients. In five of 15 patients intravascular ultrasound findings altered surgical management.Conclusion:Intravascular ultrasound is able to assess qualitative and quantitative parameters of the venous bypass and has the potential to influence surgical management based on morphologic and quantitative data

Ease of use and accuracy of a perinatal measuring device (Episiometer) to ensure correct angle and length of a mediolateral episiotomy: a mixed methods study

Introduction: To guide clinicians in performing mediolateral episiotomies (MLEs) at 60‐degrees, a new clinical innovation called the 'Episiometer' was developed. The aim of this study was to assess the usability and accuracy of the Episiometer in guiding clinicians to perform a safe episiotomy in both low‐ and high‐resource settings. Design: A prospective, multi‐site Phase‐I clinical trial was conducted between January 2017 and July 2018, involving three international study sites: Australia; Papua New Guinea; and India. The study design was mixed‐methods, incorporating an explanatory sequential design using surveys, clinician interviews and patient chart review to determine the usability and accuracy of the Episiometer. The patient chart review and results of this are discussed in an accompanying article. Methods: The Episiometer is the clinical innovation designed to attain an episiotomy cutting angle of 60‐degrees. The instrument is designed to assist clinicians to make an accurate and consistent episiotomy cutting angle within a 'safe' green zone between 45–60 degrees and length of at least 4 cm. The instrument also improves the visibility of the 60‐degree line to clinicians, and provides an exact measurement for length (located on the 60‐degree angle line). Clinicians from all three sites were recruited to provide feedback and measurements of incisions performed using the Episiometer (n = 135) following attendance at a minimum of at least one training session with site coordinators. Twenty of these clinicians were then recruited randomly from the sample who responded in the surveys and interviewed face‐to‐face. Patients were followed up 6‐weeks postpartum to monitor potential complications (n = 120). Results: Overall, the Episiometer was well received by clinicians – particularly by more junior staff members who were significantly more likely to report the Episiometer as being beneficial in guiding a safe MLE compared to their more senior counterparts (P = 0.003 and P = 0.011, respectively). In addition, 89% of incisions (107/120) were within the 'safe zone' between 45‐60 degrees, and 40% (48/120) were made at exactly 60‐degrees. No patient had any degree of perineal tear at follow up. Conclusion: The Episiometer is a well‐received clinical innovation in both high‐resource and lower resource settings. When used as directed, the Episiometer produces an accurate and safe incision, and reduces variation in clinicians' performance of episiotomy

Prematurity, Opioid Exposure and Neonatal Pain: Do They Affect the Developing Brain?

Background: Traditionally, 10 years ago, children born preterm often routinely received morphine, especially during mechanical ventilation. Studies in neonatal rats, whose stage of brain development roughly corresponds to that of children born preterm, found negative long-term effects after pain and opioid exposure. Objectives: We studied possible effects of prematurity, procedural pain and opioids in humans 10 years later. We hypothesized that these factors would negatively influence neurobiological, neuropsychological and sensory development later in life. Methods: We included 19 children born preterm who as neonates participated in an RCT on the short-term effects of morphine administration and who previously participated in our follow-up studies at ages 5 and 8/9 years. We assessed associations between brain morphology (n = 11), neuropsychological functioning (n = 19) and thermal sensitivity (n = 17) and prematurity, opioid exposure and neonatal pain. Results: Significant correlations (coefficients 0.60-0.85) of gestational age, number of painful procedures and morphine exposure with brain volumes were observed. Significant correlations between these factors and thermal sensitivity were not established. Neuropsychological outcome was significantly moderately correlated with morphine exposure in only two subtests, and children performed in general 'average' by Dutch norms. Conclusions: Although prematurity, opioid exposure and neonatal pain were significantly associated with brain volume, no major associations with neuropsychological functioning or thermal sensitivity were detected. Our findings suggest that morphine administration during neonatal life does not affect neurocognitive performance or thermal sensitivity during childhood in children born preterm without brain damage during early life. Future studies with larger sample sizes are needed to confirm these findings

High shear stress relates to intraplaque haemorrhage in asymptomatic carotid plaques

AbstractBackground and aimsCarotid artery plaques with vulnerable plaque components are related to a higher risk of cerebrovascular accidents. It is unknown which factors drive vulnerable plaque development. Shear stress, the frictional force of blood at the vessel wall, is known to influence plaque formation. We evaluated the association between shear stress and plaque components (intraplaque haemorrhage (IPH), lipid rich necrotic core (LRNC) and/or calcifications) in relatively small carotid artery plaques in asymptomatic persons.MethodsParticipants (n = 74) from the population-based Rotterdam Study, all with carotid atherosclerosis assessed on ultrasound, underwent carotid MRI. Multiple MRI sequences were used to evaluate the presence of IPH, LRNC and/or calcifications in plaques in the carotid arteries. Images were automatically segmented for lumen and outer wall to obtain a 3D reconstruction of the carotid bifurcation. These reconstructions were used to calculate minimum, mean and maximum shear stresses by applying computational fluid dynamics with subject-specific inflow conditions. Associations between shear stress measures and plaque composition were studied using generalized estimating equations analysis, adjusting for age, sex and carotid wall thickness.ResultsThe study group consisted of 93 atherosclerotic carotid arteries of 74 participants. In plaques with higher maximum shear stresses, IPH was more often present (OR per unit increase in maximum shear stress (log transformed) = 12.14; p = 0.001). Higher maximum shear stress was also significantly associated with the presence of calcifications (OR = 4.28; p = 0.015).ConclusionsHigher maximum shear stress is associated with intraplaque haemorrhage and calcifications

Measurements of morphodynamics of a sheltered beach along the Dutch Wadden Sea

A field campaign was carried out at a sheltered sandy beach with the aim of gaining new insights into the driving processes behind sheltered beach morphodynamics. Detailed measurements of the local hydrodynamics, bed-level changes and sediment composition were collected at a man-made beach on the leeside of the barrier island Texel, bordering the Marsdiep basin that is part of the Dutch Wadden Sea. The dataset consists of (1) current, wave and turbidity measurements from a dense cross-shore array and a 3 km alongshore array; (2) sediment composition data from beach surface samples; (3) high-temporal-resolution RTK-GNSS beach profile measurements; (4) a pre-campaign spatially covering topobathy map; and (5) meteorological data. This paper outlines how these measurements were set up and how the data have been processed, stored and can be accessed. The novelty of this dataset lies in the detailed approach to resolve forcing conditions on a sheltered beach, where morphological evolution is governed by a subtle interplay between tidal and wind-driven currents, waves and bed composition, primarily due to the low-energy (near-threshold) forcing. The data are publicly available at 4TU Centre for Research Data at: https://doi.org/10.4121/19c5676c-9cea-49d0-b7a3-7c627e436541 (Van der Lugt et al., 2023).</p

Prediction of final infarct volume from native CT perfusion and treatment parameters using deep learning

CT Perfusion (CTP) imaging has gained importance in the diagnosis of acute stroke. Conventional perfusion analysis performs a deconvolution of the measurements and thresholds the perfusion parameters to determine the tissue status. We pursue a data-driven and deconvolution-free approach, where a deep neural network learns to predict the final infarct volume directly from the native CTP images and metadata such as the time parameters and treatment. This would allow clinicians to simulate various treatments and gain insight into predicted tissue status over time. We demonstrate on a multicenter dataset that our approach is able to predict the final infarct and effectively uses the metadata. An ablation study shows that using the native CTP measurements instead of the deconvolved measurements improves the prediction.Comment: Accepted for publication in Medical Image Analysi

Serum insulin levels are associated with vulnerable plaque components in the carotid artery: the Rotterdam Study

Background: To investigate the association between fasting serum insulin and glucose levels with atherosclerotic plaque composition in the carotid artery. Impaired insulin and glucose levels are implicated in the etiology of cardiovascular disease; however, their influence on the formation and composition of atherosclerotic plaqu