Canadian Task Force Research Articles

Robot-assisted laparoscopic ureteral reconstruction for ureter endometriosis: Case series and literature review.

The aim of this report was to review experience from a single hospital in treating ureteral obstruction related to endometriosis with robot-assisted laparoscopic ureteral reconstruction. This retrospective analysis study (Canadian Task Force classification II-3) was conducted at an academic tertiary hospital. Five female patients with hydronephrosis without significant elevation of serum creatinine levels were enrolled. Ureteral endometriosis with obstruction was suspected on radiological images. Previous treatment with double-J stenting with or without medical treatment had failed in all of the patients. We performed robot-assisted laparoscopic segmental resection for ureteral endometriosis and reconstructed the ureter through ureteroureterostomy (RUU) or ureteroneocystostomy (RUC). The involved ureters included left lower ureter in three patients and right lower ureter in two patients. RUU was performed in four patients and RUC in one patient. All of the operations were completed smoothly without complications. All ureteral endometrioses were successfully resected, and follow-up sonography or intravenous pyelography showed resolution of hydronephrosis in all of the patients. Our experience proves the feasibility and efficacy of a robot-assisted approach for this rare situation with good outcomes.

No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline

To present evidence and recommendations regarding use, classification, interpretation, response, and documentation of fetal surveillance in the intrapartum period and to provide information to help minimize the risk of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Members of intrapartum care teams, including but not limited to obstetricians, family physicians, midwives and nurses, and their learners TARGET POPULATION: Intrapartum women OPTIONS: All methods of uterine activity assessment and fetal heart rate surveillance were considered in developing this document. The impact, benefits, and risks of different methods of surveillance on the diverse maternal-fetal health conditions have been reviewed based on current evidence and expert opinion. No fetal surveillance method will provide 100% detection of fetal compromise; thus, all FHS methods are viewed as screening tests. As the evidence continues to evolve, caregivers from all disciplines are encouraged to attend evidence-based Canadian educational programs every 2 years. Literature published between January 1976 and February 2019 was reviewed. Medline, the Cochrane Database, and international guidelines were used to search the literature for all studies on intrapartum fetal surveillance. The principal and contributing authors agreed to the content and recommendations. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care. Consistent interdisciplinary use of the guideline, appropriate equipment, and trained professional staff enhances safe intrapartum care. Women and their support person(s) should be informed of the benefits and harms of different methods of fetal health surveillance. CommunicationSupport During Active LabourPrinciples of Intrapartum Fetal SurveillanceSelecting the Method of Fetal Heart Rate Monitoring: Intermittent Auscultation or Electronic Fetal MonitoringPaper SpeedAdmission AssessmentsEpidural AnalgesiaIntermittent Auscultation in LabourElectronic Fetal Monitoring in LabourClassification of Intrapartum Fetal SurveillanceMaternal Heart RateFetal Health Surveillance Assessment in the Active Second Stage of LabourIntrauterine ResuscitationDigital Fetal Scalp StimulationFetal Scalp Blood SamplingUmbilical Cord Blood GasesDocumentationFetal Surveillance Technology Not RecommendedFetal Health Surveillance Education.

Decidualized juvenile cystic adenomyoma mimicking a cornual pregnancy

To demonstrate the laparoscopic excision technique of a juvenile cystic adenomyoma and show how the decidualization of ectopic endometrial tissue can lead to the misdiagnosis of a focus of ectopic pregnancy. Description and step-by-step demonstration of the surgical procedure using a video recording (Canadian Task Force Classification 3). Teaching and research hospital. A 27-year-old gravida 2 parity 1 patient with one previous caesarean delivery presented to the emergency department with symptoms of pelvic pain and delayed menses. Her beta-human chorionic gonadotropin level was 2,161 mIU/mL. On transvaginal ultrasonography the uterine cavity appeared empty without any signs of a gestational sac, and a 42×45 mm heterogeneous mass was observed on the right cornual area. An 18×21 mm cystic area was observed within the mass. A diagnosis of cornual pregnancy was made and two doses of systemic methotrexate treatment were administered. On the 12th day following medical treatment, the patient reported increasing abdominal pain and free fluid was observed in the pouch of Douglas on ultrasonography. The decision to perform laparoscopic cornual excision was made. On laparoscopic exploration a tubal ectopic pregnancy was observed within the left fallopian tube. The presence of two simultaneous ectopic pregnancies, located in the left fallopian tube and the right cornual area, was suspected. However, upon careful inspection, the right fallopian tube appeared normal and the mass initially thought to be a right cornual pregnancy appeared more like a degenerated fibroid. A left salpingectomy was performed and the excision of the mass in the right cornual area was planned. An incision was made over the mass and the cystic inner area containing chocolate-brown colored fluid was drained. As there was no pseudo capsule surrounding the mass, the diagnosis of focal adenomyosis instead of degenerated fibroid was made. No endometriotic foci were observed within the pelvis. Different from the enucleation of a fibroid, the mass was dissected from the middle into two halves until healthy myometrium was reached on the floor of the mass. The two halves of the mass were resected totally by dissecting the adenomyotic tissue from the myometrium starting from the caudal end towards the cranial end. The first layer of the remaining myometrial defect was sutured extracorporeally with No.1 polyglactan sutures. The second and third layers were sutured intracorporeally with V-loc sutures. The resected left fallopian tube containing the ectopic pregnancy and the adenomyotic mass were externalized through a posterior colpotomy incision. The patient was discharged 24 hours postoperatively without any complications. A diagnosis of juvenile cystic adenoma was made upon histopathological examination. The patient reported subsiding of her dysmenorrhea on the postoperative third month. Juvenile cystic adenomyosis (JCA), is a rare form of focal adenomyosis which is usually located in close proximity to the uterine insertion of the round ligament, contains a cystic inner area larger than 1 cm and is encountered before the age of 30 years. Some authors reported JCA to be an accessory and cavitated uterine mass (ACUM) anomaly developing as a result of gubernaculum dysfunction. The only difference between the two conditions is reported to be the presence of a denser area of adenomyosis surrounding the cystic area lined with endometrium in JCA than in ACUM. This case has shown that decidual changes observed in ectopic endometrial tissue within an adenomyotic area may be misdiagnosed as a focus of ectopic pregnancy. Atypical endometriomas demonstrating decidual changes may also be misdiagnosed as ovarian malignancies. In non-emergency situations, waiting for the decidualization effect of ectopic endometrium to subside can help in the definitive diagnosis of such cases. Our technique for JCA excision is different from enucleation of a fibroid and may aid in the total resection and dissection of the adenomyotic tissue from healthy myometrium.

Guideline No. 395-Female Genital Cutting.

To decrease the likelihood that the practice of female genital cutting (FGC) be continued in the future and to improve the care of girls and women who have been subjected to FGC or who are at risk by providing (1) information intended to strengthen knowledge and understanding of the practice, (2) information regarding the legal issues related to the practice, (3) guidance for the management of its obstetrical and gynaecological complications, and (4) guidance on the provision of culturally competent care to girls and women affected by FGC. Strategies for the primary, secondary, and tertiary prevention of FGC and its complications. The short- and long-term consequences of FGC. Health care providers delivering obstetrical and gynaecological care. Women from countries where FGC is commonly practised and Canadian girls and women from groups who may practise FGC for cultural or religious reasons. Published literature was retrieved through searches of PubMed, CINAHL, and the Cochrane Library in September 2010 using appropriate controlled vocabulary (e.g., Circumcision, Female) and key words (e.g., female genital mutilation, clitoridectomy, infibulation). Searches were updated and incorporated in the guideline revision December 2018. The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. There are no anticipated harms or costs to health care facilities with implementation of this guideline. Benefits may include a greater willingness of women living with FGC to seek timely care. RECOMMENDATIONS.

Screening for esophageal adenocarcinoma and precancerous conditions (dysplasia and Barrett\u2019s esophagus) in patients with chronic gastroesophageal reflux disease with or without other risk factors: two systematic reviews and one overview of reviews to inform a guideline of the Canadian Task Force on Preventive Health Care (CTFPHC)

BackgroundTwo reviews and an overview were produced for the Canadian Task Force on Preventive Health Care guideline on screening for esophageal adenocarcinoma in patients with chronic gastroesophageal reflux disease (GERD) without alarm symptoms. The goal was to systematically review three key questions (KQs): (1) The effectiveness of screening for these conditions; (2) How adults with chronic GERD weigh the benefits and harms of screening, and what factors contribute to their preferences and decision to undergo screening; and (3) Treatment options for Barrett’s esophagus (BE), dysplasia or stage 1 EAC (overview of reviews).MethodsBibliographic databases (e.g. Ovid MEDLINE®) were searched for each review in October 2018. We also searched for unpublished literature (e.g. relevant websites). The liberal accelerated approach was used for title and abstract screening. Two reviewers independently screened full-text articles. Data extraction and risk of bias assessments were completed by one reviewer and verified by another reviewer (KQ1 and 2). Quality assessments were completed by two reviewers independently in duplicate (KQ3). Disagreements were resolved through discussion. We used various risk of bias tools suitable for study design. The GRADE framework was used for rating the certainty of the evidence.ResultsTen studies evaluated the effectiveness of screening. One retrospective study reported no difference in long-term survival (approximately 6 to 12 years) between those who had a prior esophagogastroduodenoscopy and those who had not (adjusted HR 0.93, 95% confidence interval (CI) 0.58–1.50). Though there may be higher odds of a stage 1 diagnosis than a more advanced diagnosis (stage 2–4) if an EGD had been performed in the previous 5 years (OR 2.27, 95% CI 1.00–7.67). Seven studies compared different screening modalities, and showed little difference between modalities. Three studies reported on patients’ unwillingness to be screened (e.g. due to anxiety, fear of gagging). Eleven systematic reviews evaluated treatment modalities, providing some evidence of early treatment effect for some outcomes.ConclusionsLittle evidence exists on the effectiveness of screening and values and preferences to screening. Many treatment modalities have been evaluated, but studies are small. Overall, there is uncertainty in understanding the effectiveness of screening and early treatments.Systematic review registrationsPROSPERO (CRD42017049993 [KQ1], CRD42017050014 [KQ2], CRD42018084825 [KQ3]).

Fertility success rates in patients with secondary infertility and symptomatic cesarean scar niche undergoing hysteroscopic niche resection

Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain, and associated infertility. Although hysteroscopic niche resection is generally considered an effective treatment to control abnormal uterine bleeding, the impact of surgical resection on fertility outcomes is still uncertain. In the present study, we aimed to evaluate the fertility outcomes of symptomatic patients following hysteroscopic niche resection. The design in this retrospective cohort study is Canadian Task Force classification II-2 and it is carried out in a tertiary medical center (Tel-Hashomer) and a private medical center (Herzliya), both in Israel. We included all patients who underwent a niche resection between 2011 and 2015 following at least one year of infertility. From 2011 to 2015, 39 patients with a symptomatic niche and secondary infertility were treated by hysteroscopic niche resection. The patients’ mean age was 37.2 (34–41) years, mean number of gestations was 7.04 (1–16), and mean parity 5.1 (1–14). The mean number of previous cesarean sections was 3.4 (1–6). Before the surgery, 32 patients attempted and failed to conceive spontaneously and seven patients underwent in vitro fertilization (IVF) treatment and failed. One year after the hysteroscopic resection, 18 patients conceived (14 spontaneously and four following IVF), leading to a cumulative pregnancy rate of 46.15%. Among the patients who failed to conceive after at least two IVF cycles prior to the hysteroscopic resection, 42.8% conceived following surgery (three patients out of seven). Hysteroscopic niche resection should be considered an effective treatment in patients suffering from secondary infertility.PrécisHysteroscopic niche resection is a safe option for patients with symptomatic secondary infertility, resulting in acceptable fertility rates.

Method of limits: Female genital stretch perception thresholds.

Women with pelvic organ prolapse describe vaginal laxity and poor sensation of vaginal tone that does not correlate with anatomical findings. This discrepancy could be explained by altered vaginal sensation and a test that could measure sensation of vaginal tone, transmitted via Aα and Aβ nerve fibers, would further our understanding of the pathophysiology of vaginal laxity. To develop quantitative sensory testing (QST) for vaginal tone using genital stretch perception thresholds (PT), assess reproducibility, and the association with age and parity. Prospective observational cohort study of healthy women (Canadian task force classification II-2) who underwent QST method of limits at the vagina and introitus for sensation of first awareness and stretch using a modified anorectal physiology protocol. Forty women underwent repeatability testing. Intra- and inter-rater repeatability using intraclass correlation coefficients (ICC) was good to excellent for both first awareness and stretch at the vagina and introitus (intra-rater ICC = 0.93, 0.95, 0.81, and 0.88, respectively; inter-rater ICC = 0.83, 0.93, 0.71, and 0.86 respectively). Normative data were collected from 100 women. Log-linear regression found a significant association between age and PT for first awareness and stretch at the vagina and introitus (P = .020, .008, .002, and <.001, respectively). There was no association with parity and PT. Nomograms were calculated using the 95% confidence limits around the regression line. Stretch QST is clinically feasible, valid, and reproducible. The test can be used as a tool to measure sensation in women presenting with symptoms of vaginal laxity.

Revisión sistemática y análisis comparativo de las herramientas de tamizaje nutricional en pediatría validadas en Europa y Canadá

Introducción. El tamizaje nutricional es una herramienta efectiva que permite establecer el riesgo de desnutrición hospitalaria, por consiguiente es importante revisar las directrices respecto a su uso en pediatría.Objetivo. Ofrecer recomendaciones sobre el uso de las herramientas de tamizaje nutricional validadas en Canadá y Europa en población colombiana. Materiales y métodos. Se realizó una revisión sistemática siguiendo la metodología PRISMA. Para la evaluación de la calidad de la evidencia se utilizó la herramienta U.S Preventive Services Task Force, formulada para medir acciones preventivas por la Canadian Task Force on the Periodic Health Examination.Resultados. Se incluyeron 15 estudios que cumplían los criterios de selección y se identificaron 7 herramientas (PYMS, iPYMS, PeDiSMART, PNR, STAMP, PMST y STRONGkids). Según los lineamientos de la Sociedad Europea de Nutrición Clínica y Metabolismo, la PYMS, la iPYMS y la STRONGkids evalúan simultáneamente variables pronósticas como estado nutricional actual, estabilidad, progresión esperada e influencia de la enfermedad. En cuanto a validez concurrente, el análisis de datos muestra que la PYMS, la iPYMS y la PMST tienen sensibilidades &gt;85% y que la PYMS tiene especificidad &gt;85%. Respecto a reproducibilidad, la PEDISMART, la STRONGkids, la STAMP y la PYMS tienen una concordancia inter-observadores aceptable (k&gt;0.41).Conclusión. Según la evidencia analizada en términos de variables pronósticas, validez concurrente y reproducibilidad, se sugiere el empleo en la práctica clínica de la herramienta PYMS, mientras que para el uso de la STAMP y la iPYMS las instituciones deben evaluar su aplicabilidad.

Surgicopathological Outcomes and Survival in Carcinoma Body Uterus: A Retrospective Analysis of Cases Managed by Laparoscopic Staging Surgery in Indian Women.

Objectives:The context of this article is based on two main titles those being Gynecologic Oncology and Minimal invasive surgery. The aim of this study was to report the laparoscopic management of a series of cases of endometrial carcinoma managed by laparoscopic surgical staging in Indian women.Materials and Methods:This study was conducted in a private hospital (referral minimally invasive gynecological center).This was a retrospective study (Canadian Task Force Classification II-3). Eighty-eight cases of clinically early-stage endometrial carcinoma staged by laparoscopic surgery and treated as per final surgicopathological staging. All patients underwent laparoscopic surgical staging of endometrial carcinoma, followed by adjuvant therapy when needed. Data were retrieved regarding surgical and pathological outcomes. Recurrence-free and overall survival durations were measured at follow-up. Survival analysis was calculated using Kaplan–Meier survival analysis.Results:The median age of presentation was 56 years, whereas the median body mass index was 28.3 kg/m2. Endometroid variety was the most commonly diagnosed histopathology. There were no intraoperative complications reported. The median blood loss was 100 cc, and the median intraoperative time was 174 min. There were a total of 5 recurrences (5.6%). The outcome of this study was comparable to studies conducted in Caucasian population. The predicted 5-year survival rate according to Kaplan–Meier survival analysis is 95.45%, which is comparable to Caucasian studies.Conclusion:Laparoscopic management of early-stage endometrial carcinoma is a standard practice worldwide. However, there is still a paucity of data from the Indian subcontinent regarding the outcomes of laparoscopic surgery in endometrial carcinoma. The Asian perspective has been highlighted by a number of studies from China and Japan. To our knowledge, this study is the first from India to analyze the surgicopathological outcomes following laparoscopic surgery in endometrial carcinoma. The outcome of this study was comparable to studies conducted in Caucasian population.

Evaluating the Quality and Reliability of Online Information on Social Fertility Preservation.

With the rising trend of postponing motherhood, there has been an increasing rate of infertility. Social fertility preservation offers the potential to overcome this age-related infertility, and many women are turning to the Internet to seek medical information. The aim of this study was to evaluate online information on social fertility preservation. This study used five search terms-"egg freezing," "fertility preservation," "social egg freezing," "social fertility preservation," and "oocyte cryopreservation"-to identify the most popular sites as rated by Google. Accuracy of information and quality of websites were rated on the basis of four categories: Silberg's accountability criteria, Abbott's aesthetic criteria, Flesch-Kincaid readability score, and the Canadian Fertility and Andrology Society (CFAS) and the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendations (Canadian Task Force classification III). Study investigators identified the 21 most used websites. The average Silberg score was 6.57, with 85.7% of websites meeting the criteria for adequate accountability. Only one website (4.8%) did not meet the criteria for appropriate aesthetic appeal. The average Flesch-Kincaid readability score was 11.39, equivalent to a grade 11 reading level, which is significantly higher than the reading level of the general population. A total of 57% of websites contained less than half of the evidence-based recommendations provided in CFAS and SOGC recommendations. Online information on social fertility preservation is easily accessible and aesthetically pleasing, but information is not easily readable and does not reflect evidence-based recommendations. Hence, health care professionals must fill the knowledge gaps and adequately counsel their patients to optimize a woman's chance at a successful pregnancy.

Examining Cesarean Section Rates in Canada Using the Modified Robson Classification.

Canada's cesarean delivery (CD) rate continues to increase. The Society of Obstetricians and Gynaecologists of Canada advocates the use of the modified Robson classification for comparisons. This study describes national and provincial CD rates according to this classification system. All 2016-2017 in-hospital births in Canada (outside Québec) reported to the Discharge Abstract Database were categorized using the modified Robson classification system. CD rates, group size, and contributions of each group to the overall volume of CD were reported. Rates by province and hospital peer group were also examined (Canadian Task Force Classification III). A total of 286201 women gave birth; among these, 83262 (29.1%) had CDs. Robson group 5 (term singleton previous CD) had a CD rate of 80.5% and was the largest contributing group to the overall number of CD (36.6%). Women whose labour was induced (Robson group 2A) had a CD rate almost double the rate of women with spontaneous labour (Robson group 1): 33.5% versus 18.4%. These latter two groups made the next largest contributions to overall CD (15.7% and 14.1%, respectively). There were substantial variations in CD rates across provinces and among hospital peer groups. The study found large variations in CD rates across provinces and hospitals within each Robson group, thus suggesting that examining variations to determine the groups contributing the most to CD rates (Robson groups 5, 2A, and 1) may provide valuable insight for reducing CD rates. This study provides a benchmark for measuring the impact of future initiatives to reduce CD rates in Canada.

The Edmonton Obesity Staging System Predicts Mode of Delivery After Labour Induction.

This study sought to evaluate the use of the Edmonton Obesity Staging System (EOSS) in predicting cesarean delivery among term, nulliparous, singleton pregnancies in women with overweight or obesity who are undergoing an induction of labour. A prospective cohort study was performed in Edmonton, Alberta. Women undergoing an induction of labour at term were recruited to either a sample cohort, including women with a body mass index of ≥25 kg/m2 at first antenatal visit, or a control cohort with a body mass index of 18.5 to 24.9 kg/m2. Participating women provided a self-reported health history and consented to review of their medical records allowing allocation into EOSS categories. The primary outcome was the rate of cesarean delivery based on EOSS category. Secondary outcomes consisted of a summary score of adverse maternal, delivery, and neonatal events (Canadian Task Force Classification II-2). Overall, 345 women were recruited, with a participation rate of 93.7%. The sample cohort consisted of 276 women with overweight or obesity, whereas the control cohort included 69 normal-weight women. The overall rate of cesarean delivery was 30.4% for the control cohort and 35.8%, 29.9%, 43.2%, and 90.5% for women assigned an EOSS category 0, 1, 2, and 3, respectively (P < 0.001). A summary score was not indicative of overall rate of adverse maternal, delivery, and neonatal events (P = 0.22). The EOSS may help predict the chance of cesarean delivery in a high-risk group of nulliparous women with overweight or obesity who are undergoing an induction of labour at term.

Prevalence of Low Back Pain, Pelvic Girdle Pain, and Combination Pain in a Postpartum Ontario Population.

The purpose of this study was to determine the point prevalence of low back pain (LBP), pelvic girdle pain (PGP), and/or combination pain (COMBO pain) and period prevalence (presence or absence of any of those pains), as well as to identify risk factors at 1, 3, and 6 months postpartum in a Canadian population. Participants from a previous pregnancy study participated in a postpartum survey administered over the telephone at 1, 3, and 6 months following delivery. The survey included questions about LBP, PGP, or COMBO pain during the postpartum period, as well as questions related to risk factors (Canadian Task Force Classification II-3). At 1, 3, and 6 months postpartum, responses from 46, 58, and 64 participants, respectively, demonstrated that 15%-21% of women experienced LBP and up to 4% of women experienced COMBO pain (point prevalence). At no time point was PGP reported to occur alone. Period prevalence of back pain for the participants returned to pre-pregnancy levels at each time point. Back pain during pregnancy was the only risk factor identified for back pain at 3 and 6 months postpartum. This study demonstrated that 76% to 80% of respondents were pain free at 1, 3, and 6 months postpartum. Pregnancy-related back pain was the only risk factor associated with postpartum-related pain at the 1 to 3 and 3 to 6 month time interval. Identification of site-specific postpartum-related back pain may assist in determination of management and treatment plans for this population.

MR scan evaluation of pelvic organ prolapse mesh complications and agreement with intra-operative findings

IntroductionAn increasing number of women are presenting with symptoms after the placement of mesh implants for prolapse which may be attributable to a mesh implant complication. MRI imaging can be used to evaluate abdominally placed mesh but there is no published research evaluating the use of MRI in this group of women. The objective of our study was to report our experience as a tertiary centre in evaluating abdominal mesh with MR imaging and the agreement of MR reports with surgical findings.Study designA retrospective observational cohort study (Canadian Task Force classification II-2) of all women referred to our tertiary unit who underwent an MR scan for investigation of symptoms of mesh complication following an abdominally placed mesh implant between June 2006 and September 2018 was performed. The reports of MR images were compared with the findings at surgery.ResultsMR scan was performed in 87 with suspected mesh complications. MR scan detected mesh failure in 42.1% of women (37/87), infection in 12.6% (11/87), compression in 2.3% (2/87), exposure in 12.6% (11/88), bowel extrusion in 2.3% (2/87) and inflammation in 11.5% (10/87). Agreement between MR scan report and surgical diagnosis was almost perfect for mesh failure, infection and compression, whilst agreement was only moderate for mesh erosion and signs of inflammation (failure κ = 0.97, infection κ = 0.94, compression κ = 1.0, exposure κ = 0.58 and inflammation κ = 0.24).ConclusionThese data provide information on the role of MR imaging in the investigation of women presenting with suspected intra-abdominal POP mesh complications including recurrence.

A Nationwide Needs Assessment to Identify and Prioritize Technical Procedures for Simulation in Obstetrics and Gynaecology: A Delphi Study.

The aims of the study were to identify and prioritize technical procedures that should be developed and integrated in a simulation-based curriculum for obstetrics and gynaecology residents. The Delphi method was used, consisting of three rounds of survey questionnaires. Key leaders across Denmark were invited to participate. In Delphi round 1, the participants individually identified technical procedures that newly authorized specialists should be able to perform. These procedures were sent to round 2 to be explored for need for simulation-based training by estimating frequency of procedures, number of doctors, potential patient risk and/or discomfort, and feasibility of simulation. Round 3 consisted of elimination and prioritization of remaining procedures (Canadian Task Force Classification III). A total of 165 key leaders were invited. Response rates were 61%, 50%, and 53%, respectively. Identified procedures in Round 1 were as follows: gynaecology (n = 51), obstetrics (n = 40), and general procedures (n = 10). A needs assessment formula was used to calculate needs for training on the basis of the answers in round 2 and produce a preliminary prioritized list that was sent to round 3 for final exploration. Round 3 consisted of elimination and final prioritization, where gynaecology (n = 17) prioritized basic laparoscopy, vaginal ultrasound, and laparoscopy with salpingostomy and salpingectomy; obstetrics procedures (n = 16) prioritized basic resuscitation of newborn, vacuum extraction, and management of shoulder dystocia; and one general procedure (basic adult resuscitation) was included. A needs assessment using the Delphi method produced a prioritized list of technical procedures suitable for simulation. This can guide the development of simulation-based training programs.

Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study.

This study aimed to quantify adverse neonatal outcomes in a cohort of registered midwife (RM)-attended conventional and water births in British Columbia. The study included all term singleton births in British Columbia between January 1, 2005 and March 31, 2016 attended by RMs. Births were allocated to a conventional birth cohort or a water birth cohort according to where the actual birth of the neonate took place. The primary outcome was a composite adverse neonatal outcome (Apgar <7 at 5 minutes, resuscitation need, neonatal intensive care unit admission). Secondary outcomes included individual components of the primary outcome, maternal length of labour, and degree of perineal laceration (Canadian Task Force Classification Level II-2). The population included 25798 births. Of these, 23201 were conventional, and 2567 were water births. The rate of the composite adverse neonatal outcome was not higher in water births compared with conventional births (hospital conventional, 5.0%; hospital water, 4.2%; home conventional, 3.4%; and home water, 2.9%). Rates of individual components of the composite adverse neonatal score were not greater in the water birth cohort. Maternal outcomes included statistically shorter labours in the water birth cohort and no difference between the cohorts in incidence of third- and fourth-degree lacerations. Water births attended by RMs in British Columbia are not associated with higher rates of adverse neonatal outcomes than conventional births attended by midwives.

Dye diffusion during laparoscopic tubal patency tests may suggest a lymphatic contribution to dissemination in endometriosis: A prospective, observational study.

AimWomen with adenomyosis are at higher risk of endometriosis recurrence after surgery. This study was to assess if the lymphatic vessel network drained from the uterus to near organs where endometriosis foci lied.MethodsA prospective, observational study, Canadian Task Force Classification II-2, was conducted at Sacro Cuore Don Calabria Hospital, Negrar, Italy. 104 white women aged 18–43 years were enrolled consecutively for this study. All patients underwent laparoscopy for endometriosis and a tubal dye test was carried out.ResultsEvidence of dye dissemination through the uterine wall and outside the uterus was noted in 27 patients (26%) with adenomyosis as it permeated the uterine wall and a clear passage of the dye was shown in the pelvic lymphatic vessels regardless whether the tubes were unobstructed. Histological assessment of the uterine biopsies confirmed adenomyosis.ConclusionAdenomyosis is characterized by ectatic lymphatics that allow the drainage of intrauterine fluids (the dye and, perhaps, menstrual blood) at minimal intrauterine pressure from the uterine cavity though the lymphatic network to extrauterine organs. Certainly, this may not be the only explanation for endometriosis dissemination but the correlation between the routes of the dye drainage and location of endometriosis foci is highly suggestive.

Laparoscopic In-Bag Morcellation Compared with Conventional Morcellation of Myomas and Uterus with Myomas.

To evaluate contained bag electromechanical morcellation for removal of myomas and uterus with myomas, laparoscopically (Study group B), and compare it with uncontained laparoscopic morcellation (Control group A) in patients with similar parameters done earlier. Retrospective Cohort Comparative Study (Canadian Task Force 2-1). Advanced Gynaecologic MAS, university recognized tertiary centre, Mumbai, India. 720 women had laparoscopic removal of myomas or large uterus with myomas during a study period of 6years (from 13 May 2012 to 14 August 2018) with contained bag electromechanical or conventional morcellation. Laparoscopic hysterectomy, laparoscopic myomectomy, conventional uncontained morcellation, contained in-bag morcellation. Laparoscopic contained in-bag morcellation was compared with conventional morcellation of myomas and uterus with large myomas during a study period of 6years. Parameters assessed were operating time, time for insertion of bag, morcellation of tissues and removal of bag, blood loss, complications, conversion to open surgery and histopathologic findings of tissues. In Group A, in the first 3years, 355 women underwent uncontained morcellation. Myoma size and weight varied from 5 cm to 26 cm and 200 g to 3740 g respectively. The myoma number ranged from 1 to 18. No case of leiomyosarcoma was reported. In Group B, in the next 3years, 365 women underwent contained bag morcellation in 196 myomectomy cases and 169 hysterectomy cases. Myoma size and weight varied from 4 cm to 20 cm and 200 g to 2100 g respectively. The number of myomas varied from 1 to 17. Laparoscopic contained bag morcellation for myomas and uterus with large myomas were evaluated. In myomectomy group both conventional and in bag laparoscopic morcellation were comparable in terms of duration of the surgery and blood loss. When all cases ( hysterectomy and myomectomy combined together) and cases of hysterectomy with large fibroid were studied, laparoscopic in bag morcellation took less operative time and there was statistically significant difference in operative time . No case of leiomyosarcoma was found in our study of 720 cases of myomas or uterus with large myomas.

Chronic Periodontitis and Hypertension:A Systematic Review

Aim: To conduct a systematic review evaluating associations between periodontal disease and hypertension. Method: A MEDLINE literature search of papers published between 2000 and March 2016 was conducted. Cross-sectional studies, prospective studies and nested case-control studies that studied the association between periodontitis and hypertension formed the mainstay of this literature review. This systematic review was conducted on the guidelines of the Cochrane Systematic Reviews and the conclusive evidence was based on the Canadian task force on preventive health care guidelines. Results: A total of 21 articles were searched for relevancy, determined by article title, abstract and full copy, resulting in a yield of 17 studies that met our inclusion criteria. 1) There is a fair evidence (II-2 Grade B recommendation) for an association between chronic periodontitis and blood pressure with OR of 2.93 (95% CI:1.25-6.84) but the association becomes stronger when restricted with those with hypertension or taking anti-hypertensive medications: OR = 4.20(95% CI:1.28-13.80). 2) A good evidence (I, Grade A recommendation) that intensive periodontal therapy decrease cardiovascular risk scores (Framingham) at 296 mm (1.53% F 1.20% (95% CI 1.05-2.24, P = .0290) and 2.00% F 1.42% (95% CI 0.98-4.09, P = .0568). Conclusions: With the available literature we conclude that, 1. There is a fair evidence for an association between chronic periodontitis and hypertension. 2. Intensive periodontal therapy reduces the systemic inflammatory markers and systolic blood pressure imminently at 6 months after the end of periodontal treatment.

Massive recurrent hemoperitoneum with encapsulating peritonitis: another enigmatic clinical feature of endometriosis

To describe the clinical characteristics and laparoscopic findings of a very uncommon presentation of a patient with endometriosis. Video presentation of case report (Canadian Task Force classification III). (The institutional review board of the Hospital Naval Pedro Mallo, Buenos Aires, Argentina, has ruled that approval was not required for the publication of this case report.) SETTING: Hospital. Thirty-two-year-old woman with endometriosis presenting with hemorrhagic ascites. We demonstrate the laparoscopic appearance of the peritoneal organs in the presence of massive hemoperitoneum and encapsulating peritonitis and also describe the diagnosis and management options of an uncommon clinical presentation of endometriosis. The patient is a 32-year-old woman, gravida 0, who presented with abdominal pain and ascites. Initially, she underwent exploratory laparotomy with drainage of 5liters of ascites and excision of endometrial peritoneal implants. She then presented 4months later with sudden worsening abdominal pain and distention, weight gain, bloating, and shortness of breath. A diagnostic laparoscopy was performed with the findings of over 10liters of dark hemoperitoneum and diffuse pelviperitonitis with loose necrotic, easy to remove, dense peritoneal tissue. Patient was started on triptorelin acetate with great response. Resolution of the symptomatology secondary to hemorrhagic peritonitis. Clinical improvement of symptomatology of a patient with endometriosis and hemorrhagic ascites. Endometriosis can have different clinical presentations. Endometriosis should be a differential diagnosis in women of reproductive age presenting with massive hemorrhagic ascites. Hemorrhagic ascites, considered an exceedingly rare clinical course of endometriosis, represents a challenge to the surgeon who is unfamiliar with this condition. Bilateral oophorectomy is the definitive treatment, but conservative therapy is indicated for women of childbearing age. Diagnostic laparoscopy with drainage of hemoperitoneum is a feasible option to obtain a pathology-confirmed diagnosis in patients presenting with hemoperitoneum secondary to pelvic endometriosis. Awareness of this condition will prevent unnecessary aggressive resection, as is commonly performed when the condition is confused with ovarian cancer.