Assessment of late on-set fetal growth restriction using SMI (superb microvascular imaging) Doppler.

Background: The identification of late-onset fetal growth restriction (FGR) fetuses remains a challenge, given the difficulty to distinguish them from healthy small for gestational age (SGA) fetuses. Given the limitations of conventional Doppler for the identification of placental insufficiency, the appearance of superb microvascular imaging (SMI) Doppler seems promising. Our main objective was to evaluate the diagnostic capability of SMI Doppler for the detection of placental insufficiency findings. Methods: A prospective observational study was conducted at a tertiary care center, including 51 patients who had been diagnosed with late on-set SGA or FGR. A placental ultrasonographic evaluation was carried out using SMI Doppler. Patients were sorted into two groups attending to the histologic evaluation of the placentas after delivery: Group 1 (21 cases), Normal group; and Group 2 (30 cases), FGR group. Results: Placentas in the FGR group had lower peak systolic velocity (PV) values of the chorionic plate. The PV of the other vessels were consistently lower in the FGR group that in the normal group, although without reaching statistical significance. Conclusions: The PV of the chorionic plate measured with SMI Doppler, have the capacity to identify placental insufficiency findings. Ultrasonographic placental assessment using SMI Doppler appears to be a useful technique for the evaluation of suspected late on-set placental insufficiency.

Is It Possible to Diagnose Surgical Uterine Prolapse With Transperineal Ultrasound? Multicenter Validation of Diagnostic Software.

OBJECTIVES: To validate an ultrasound software that uses transperineal ultrasound to diagnose uterine prolapse (UP). METHODS: Multicenter, observational and prospective study with 155 patients that had indications for surgical intervention for dysfunctional pelvic floor pathology. Each patient underwent an examination with Pozzi tenaculum forceps was performed in the operating room with the patient anesthetized, followed by surgical correction of stages II-IV UP. Transperineal ultrasound was used to assess the difference in the pubis-uterine fundus measurement. With a multivariate logistic regression binary model (with the measurement ultrasound at rest, the Valsalva maneuver and age) using nonautomated methods to predict UP. With the purpose of evaluating the model, a table with coordinates of the receiver operating characteristic (ROC) curve, after which sensitivity and specificity were assessed. RESULTS: A total of 153 patients were included (73 with a diagnosis of surgical UP). It was obtained from the AUC (0.89) of the probabilities predicted by the model (95% confidence interval, 0.84-0.95; P < .0005). Based on the ROC curve for the model, obtaining a sensitivity of 91.8% and a specificity of 72.7%, values that were superior to those for the clinical exam for surgical UP (sensitivity: 80.8%; specificity: 71.3%). CONCLUSIONS: We validated software that uses transperineal ultrasound of the pelvic floor and patient age to generate a more reliable diagnosis of surgical UP than that obtained from clinical examinations.

Transvaginal ultrasonography predictive model for the detection of pelvic congestion syndrome.

Background: The diagnosis of pelvic congestion syndrome (PCS) remains a challenge given the lack of universally accepted criteria. Although venography (VG) is the current gold standard for the diagnosis of PCS, non-invasive techniques like transvaginal ultrasonography (TVU) appear to be a valid alternative. The aim of this study was to design a predictive model for the venographic diagnostic of PCS using the parameters identified by TVU in patients with clinical suspicion of PCS, in order to individually assess the need to perform an invasive diagnostic and therapeutic technique such as VG. Methods: An observational and cross-sectional prospective study was conducted including 61 consecutively recruited patients with clinical suspicion of PCS, who were referred by the Pelvic Floor, Gynecology and Vascular Surgery Units, who were distributed in two groups: 18 belonging to the normal group and 43 to the PCS's group. We implemented and compared 19 binary logistic regression models, including the parameters that showed statistical significance in the prior univariate analysis. We evaluated individual predictive values with a receiver operating characteristic (ROC) curve and the area under the curve (AUC). Results: The selected model, based on the presence of pelvic veins or venous plexus of 8 mm or larger, observed by transvaginal ultrasound, had an AUC of 0.79 (95% CI: 0.63-0.96; P<0.001), with a sensitivity of 0.90 and specificity of 0.69, while the VG had a sensitivity of 86.05%, a specificity of 66.67%, and a positive predictive value of 86.05%. Conclusions: This assessment presents a feasible alternative that could potentially be added to our usual gynecological practice.

Identification of Surgical Uterine Prolapse in Premenopausal Patients With Clinical or Ultrasound Criteria? A Multicenter Comparative Study.

OBJECTIVES: It is unknown whether diagnosing uterine prolapse (UP) via ultrasound or surgical criteria is superior. Our objective is to determine whether the diagnostic capacity of ultrasound with surgical criteria differs from that of surgical criteria only. METHODS: This was a multicenter prospective observational study with 54 premenopausal patients with surgical criteria for a dysfunctional pelvic floor pathology who were consecutively recruited for 1 year. Clinical UP with surgical criteria was defined when UP stage II-IV was identified (during pelvic floor consultation), and UP diagnosed by ultrasound with surgical criteria was established when a difference ≥15 mm was found between rest and Valsalva applied to the pubis-uterine fundus. The sensitivity, specificity and positive and negative predictive values were determined to evaluate clinical and ultrasound methodologies as diagnostic tests. RESULTS: UP diagnosed by ultrasound with surgical criteria presented better sensitivity (78.57 vs 35.71%), specificity (92.11 vs 81.58%), positive predictive value (61.83 vs 23.99%), and negative predictive value (96.35 vs 11.37%) than UP diagnosed by surgical criteria only. CONCLUSION: Ultrasound with surgical criteria is superior to surgical criteria alone when diagnosing UP.

Reproducibility of the anorectal angle with transperineal ultrasound.

Background: The anorectal angle (ARA) has been assessed with different imaging methods and its measurement has traditionally been based on defecography or magnetic resonance studies. Different ultrasound methodologies have also been used for ARA assessment and have been validated as alternatives for the ARA measurement, such as three-dimensional (3D) endovaginal ultrasound and 3D transperineal ultrasound. 3D transperineal ultrasound does not require the introduction of ultrasound transducers inside the anal canal. Therefore, it is reasonable to think that the use of transperineal ultrasound can provide more reproducible ARA measurements, something that has not been established by 3D endovaginal probe or defecography. Our objective is to determine the intraobserver and interobserver variability of transperineal ultrasound for the assessment of ARA. Methods: A retrospective observational study was performed with 40 patients. The study of the ARA was performed from the mid-sagittal plane (at rest, Valsalva and maximum contraction), visualizing the anorectal canal, the anorectal junction and the rectal ampulla. ARA measurements were performed initially by explorer 1 (E1), subsequently by explorer 2 (E2) and finally again by E1. Intraobserver and interobserver variability was calculated by calculating the intraclass correlation coefficient (ICC) with 95% confidence interval (CI). Results: Intraobserver variability was excellent for all measurements of the ARA at rest, Valsalva and maximal contraction, with ICC ranging from 0.968 to 0.975. Interobserver variability was also superb for all measurements of the ARA at rest, Valsalva and maximal contraction, with ICC ranging from 0.971 to 0.979. Conclusions: Intraobserver and interobserver variability were excellent for the ARA measurements by transperineal ultrasound.

Can Intrapartum Ultrasonography Improve the Placement of the Vacuum Cup in Operative Vaginal Deliveries?

Although the fetal head position has traditionally been evaluated by digital examination (DE), it has a failure rate ranging between 20 and 70%; hence, intrapartum transabdominal ultrasonography (TUS) has become relevant. We aimed to evaluate the utility of the TUS to identify the fetal head positions in vacuum-assisted deliveries. We performed a prospective observational study including 101 pregnant patients in active labor who required a vacuum-assisted delivery. The fetal head position was assessed by a DE and a TUS prior to vacuum cup placement. After delivery, the optimal vacuum cup placement was evaluated as the distance between the chignon and the flexion point ≤2 cm. The general concordance rate between the DE and TUS was 72.2%, with the poorest concordance rate for occiput posterior positions at 46.1%. In five cases (4.9%), it was not possible to determine the fetal head position through the DE. The correlation was higher in low and medium planes, with 77% and 68.1% concordance rates, respectively, while it was lower in high planes (60%). In 90.1% of cases, the vacuum cup placement was optimal. Our findings show that intrapartum transabdominal ultrasonography is a useful technique to identify the fetal head position allowing optimal placement of the vacuum cup necessary for correct vacuum-assisted delivery.

Multicenter study of the evolution of different types of avulsion over the 12 months after delivery.

OBJECTIVE: To perform a multicenter study of muscle recovery in levator ani muscle (LAM) avulsion during the first 12 months postpartum according to the type of LAM avulsion suffered. METHODS: This was a multicenter prospective observational study including 242 primiparas. Transperineal ultrasound was performed at 6 months and 12 months after delivery. Type I LAM avulsion was present when most of the lateral fibers of the pubovisceral muscle were observed at the muscle's insertion at the pubic level. Type II LAM avulsion was defined as complete detachment of the pubovisceral muscle from its insertion at the pubic level. RESULTS: Among the 56 patients who completed the study (with ultrasound at 6 and 12 months after delivery), 76 avulsions (10 cases of bilateral avulsion) were identified at 6 months after delivery, and the total number of avulsions had decreased to 58 at 12 months after delivery (P < 0.001; 95% confidence interval [CI] 13.9%-33.5%). This decrease was due to the disappearance of 69.2% of the cases of Type I LAM avulsions (P < 0.001; 95% CI: 50.2%-88.2%). However, the number of Type II LAM avulsions remained constant at 6 months and 12 months after delivery. CONCLUSION: The spontaneous resolution of LAM avulsion during the first 12 months postpartum occurs in cases of Type I LAM avulsion but is not observed in Type II LAM avulsion.

Monitoring of metals and metalloids from maternal and cord blood samples in a population from Seville (Spain).

Nowadays there is an increasing concern about exposition during prenatal stage to environmental pollutants such as metals, that make pregnant women a vulnerable group of population. Numerous studies have shown associations between the prenatal exposition to some metals and an impact on cognitive, motor and intellectual development of the child. Metals and metalloid are ubiquitous in the environment and pregnant women are exposed to them though their diet, lifestyle factors or occupational and environmental sources. One hundred of maternal and one hundred of cord blood samples were obtained at delivery from pregnant women after signing of the informed consent to determine simultaneously levels of Al, As, Cd, Cr, Cu, Hg, Mn, Ni, Pb, Se and Zn by ICP-MS. Among these metals, essential ones (Cu, Mn, Se and Zn) can have health beneficial effects at low levels, however, in high concentration are potentially toxic. On the other hand, elements such as Al, As, Cd, Hg, Pb are classified as toxic metals, no matter what its concentration was. The aim of this study was to find the potential relationships between these metals and metalloid levels, newborn's parameters, pregnancy details and the epidemiologic information obtained using a questionnaire data from the participant pregnant women from Seville (Spain). A n = 100 of participants have been enrolled, 15.6 % of the women from Virgen del Rocio Hospital were smokers during pregnancy but only 11.1 % from Virgen de Valme had the habit. Dietary habits of all participants from both hospital were quite similar in average rice, fish and canned food consumption. The characteristics of newborns were also quite similar for both hospitals. A positive correlation between maternal and cord blood was found between all metals except for Cr and Cu. The strongest correlation was found for Hg (r = 0.779, p < 0.005). Positive but weaker correlations between maternal blood and lifestyle habits were also established.

Are Transperineal Ultrasound Parameters Useful to Predict Incontinence in Patients with Single-Incision Mini-Slings?

It would be logical to think that single-incision mini-slings (SIMS) should behave like the rest of the tension-free vaginal tape and, therefore, to believe that they present a similar ultrasound appearance, but there are no studies on this matter. Therefore, the main aim of our research is to determine which ultrasound parameters are associated with stress urinary incontinence (SUI) in patients carrying SIMS. A prospective observational study was carried out including 94 patients who were candidates for SUI corrective surgery with SIMS between 1 January 2021 to 31 December 2021 at the Universitary Hospital of Valme (Seville, Spain). A transperineal ultrasound evaluation was performed (six months after surgery) in order to study: the bladder neck-symphyseal distance, the posterior urethro-vesical angle, the pubic symphysis-tape gap, the tape-urethral lumen distance, the sagittal tape angle, the tape position, the concordance of movement between the tape and the urethra, and the axial tape angle. A total of 92 patients completed the study (63 asymptomatic and 29 symptomatic). Statistical differences were observed in the concordance of movement between the tape and the urethra (84.1% vs. 25.0%; p: 0.001) and in the axial tape angle at rest (139.3 ± 19.0 vs. 118.3 ± 15.4; p: 0.003) and at Valsalva (145.1 ± 20.2 vs. 159.1 ± 9.0; p: 0.034). Sagittal tape angle at rest was higher in urge urinary incontinence (UUI) patients (132.5 ± 35.7 vs. 143.3 ± 29.8; p: 0.001) and mixed urinary incontinence (MUI) patients (132.5 ± 35.7 vs. 157.8 ± 23.6; p: 0.025) compared to asymptomatic patients. In conclusion, the concordance between the movement of the tape and the urethra is the most useful ultrasound parameter to define continence in patients with SIMS.

Can clinicopathological factors improve the prediction of metastasis to nonsentinel lymph nodes in patients with breast cancer?

INTRODUCTION: To determine whether clinicopathological characteristics can improve the prediction of metastasis to nonsentinel lymph nodes (NSLNs) over the use of only mRNA copy number in sentinel lymph node (SLN) biopsies. METHODS: This was a retrospective, observational study that included a total of 824 patients with T1-3 breast cancer who had clinically negative, ultrasound-negative axilla without evidence of metastasis and who underwent one-step nucleic acid amplification in SLN biopsies. RESULTS: 118 required a complete axillary lymph node dissection (ALNhD). About 35.6% (42/118) had metastases to a NSLN, and 64.4% (76/118) had no metastasis to a NSLN. The ROC curve of the total tumor load (TTL) presented an area under the curve (AUC) of 0.651 (95%; CI: 0.552-0.751). The 7294 copies of CK19 mRNA were established as the optimal cutoff point, with sensitivity: 93%, specificity: 63%, positive predictive value: 44%, and negative predictive value: 91%. By associating the clinicopathological parameters (multicentricity, pooled immunohistochemistry [IHC], and progesterone receptors), the AUC went up to 0.752 (95% CI: 0.663-0.841). CONCLUSIONS: Clinicopathological factors should be considered together with the total CK19 mRNA copy number (the TTL) of the SLNs to improve the predictive capacity of metastatic involvement of the NSLNs.

INTRODUCCIÓN: Nuestro objetivo era determinar si la influencia de las características clínicopatológicas pueden mejorar la predicción de metástasis en los ganglios linfáticos no centinelas (GLNC) a partir de un punto de corte de copias de ARNm determinado en la biopsia del ganglio linfático centinela (GLC). MÉTODOS: Se realizó un estudio observacional retrospectivo incluyendo a un total de 824 pacientes con cáncer de mama T1-3, con axila clínica y ecográficamente negativa para metástasis en los ganglios axilares. Se les practicó una biopsia selectiva del GLC y estudio posterior mediante el método one step nucleic acid amplification (OSNA). RESULTADOS: 118 precisaron una disección completa de los ganglios linfáticos axilares. 35,6% (42/118) tuvieron metástasis en GLNC y 64.4% (76/118) no presentaron metástasis en GLNC. La curva ROC del log de la carga tumoral total (CTT) presentó un área bajo la curva de 0.651 (95%; IC: 0.552-0.751). Se estableció las 7294 copias de ARNm de CK19 como punto de corte óptimo, con sensibilidad: 93%, especificidad: 63%, valor predictivo positivo: 44% y valor predictivo negativo: 91%. Al asociar los parámetros clinicopatológicos (multicentricidad, inmunohistoquímica (IHQ) agrupado y receptores de progesterona) obtenemos un área bajo la curva mejorada de 0.752 (95% intervalo de confianza [IC] 0.663-0.841). CONCLUSIONES: Los factores clinicopatológicos deberían valorarse asociados al corte de copias de ARNm de la CTT de CK19 de los GLCs para mejorar la capacidad predictiva de afectación metastásica en los GLNCs.

Predictive Model for the Diagnosis of Uterine Prolapse Based on Transperineal Ultrasound.

We want to describe a model that allows the use of transperineal ultrasound to define the probability of experiencing uterine prolapse (UP). This was a prospective observational study involving 107 patients with UP or cervical elongation (CE) without UP. The ultrasound study was performed using transperineal ultrasound and evaluated the differences in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. We generated different multivariate binary logistic regression models using nonautomated methods to predict UP, including the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. The parameters were added progressively according to their simplicity of use and their predictive capacity for identifying UP. We used two binary logistic regression models to predict UP. Model 1 was based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient [AUC: 0.967 (95% CI, 0.939−0.995; p < 0.0005)]. Model 2 used the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver, age, avulsion and ballooning (AUC: 0.971 (95% CI, 0.945−0.997; p < 0.0005)). In conclusion, the model based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient could predict 96.7% of patients with UP.

The Role of Transperineal Ultrasound for the Assessment of the Anorectal Angle and Its Relationship with Levator Ani Muscle Avulsion.

The relationship between the anorectal angle (ARA) and the levator ani muscle (LAM) is well known. In this study, we aimed to demonstrate that the ARA changes when LAM avulsion occurs after vaginal delivery. This was a secondary, observational retrospective study with data obtained from three previous studies. Using transperineal ultrasound, the presence of avulsion was assessed when abnormal insertion of the LAM was observed in three central slices. In addition, the ARA was assessed in the midsagittal plane (at rest, in Valsalva and at maximum contraction) as the angle between the posterior border of the distal part of the rectum and the central axis of the anal canal. The ARA was higher in patients with bilateral LAM avulsion than in patients without LAM avulsion at rest (131.8 ± 14.1 vs. 136.2 ± 13.8), in Valsalva (129.4 ± 15.5 vs. 136.5 ± 14.4) and at maximum contraction (125.7 ± 15.5 vs. 132.3 ± 13.2). The differences between both groups expressed as the odds ratio (OR) adjusted for maternal age were 1.031 (95% confidence interval (CI), 1.001-1.061; p = 0.041) at rest, 1.036 (95% CI, 1.008-1.064; p = 0.012) in Valsalva and 1.031 (95% CI, 1.003-1.059; p = 0.027) at maximum contraction. In conclusion, LAM avulsion produces an increase in the ARA at rest, during contraction and in Valsalva, especially in cases of bilateral LAM avulsion.

Quantification of 3/4D ultrasound pelvic floor changes induced by postpartum muscle training in patients with levator ani muscle avulsion: a parallel randomized controlled trial.

Background: We believe that physiotherapy with muscle training (MT) of the postpartum pelvic floor may lead to a change in the clinical management of patients with avulsion of the puborectal portion of the levator ani muscle (LAM). Our objective is to assess whether physiotherapy with MT of the postpartum pelvic floor in patients with LAM avulsion produces changes in pelvic floor morphology evaluated by 3/4D transperineal ultrasound. Methods: This parallel randomized controlled trial (RCT) included 97 primiparous patients. A study was conducted in three parts. In the first part (3 months postpartum), primiparous patients with LAM avulsion were recruited, and the levator hiatus and the LAM areas were measured using 3/4D transperineal ultrasound. In the second part (3 to 6 months postpartum), patients were randomized into two groups, with one undergoing rehabilitation (experimental group) and another without rehabilitation (control group). At the end of 6 months, a new transperineal ultrasound was performed. In the third part (9 months postpartum), the levator hiatus and LAM dimensions were analyzed again. The RCT was registered at ClinicalTrials.gov (NCT03686956). Project PI16/01387 funded by Instituto de Salud Carlos III (Spain) integrated in the national I+D+i 2013-2016 and cofounded by the European Union (ERDF/ESF, "Investing in your future"). Results: A total of 92 completed the study, including 46 patients in the experimental group and 46 in the control group. The experimental group had a greater LAM area at 6 months (9.2±1.9 vs. 7.6±2.1 cm2, P=0.008; 95% CI: 0.6-3.0) and 9 months after labor (9.4±2.7 vs. 7.6±2.0 cm2, P=0.012; 95% CI: 0.4-3.2), which was not observed at 3 months postpartum (8.3±1.6 vs. 7.5±2.3 cm2; P=0.183; 95% CI: 0.39-1.99). The levator hiatus area decreased more in the experimental group in almost all comparisons. The most significant change occurred from 3 to 6 months during the Valsalva maneuver (-3.92±5.12 vs. 0.45±3.06 cm2; P<0.005; 95% CI: 2.64-5.00). Conclusions: Women with a rehabilitated LAM through physiotherapy showed a significant reduction in the levator hiatus area during Valsalva while receiving in-person physical therapy (3 to 6 months after delivery). These differences did not persist once physical therapy was completed (6 to 9 months after delivery). Trial Registration: ClinicalTrials.gov identifier NCT03686956.

2D ultrasound diagnosis of middle compartment prolapse: a multicenter study.

BACKGROUND: Recently, a specific methodology has been defined, using transperineal ultrasound, for the differential diagnosis of middle compartment prolapse [uterine prolapse (UP) or cervical elongation (CE) without UP] based on the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver, with a cutoff point of 15 mm. The objective of this study was to validate the diagnostic utility of a ≥15 mm difference between the pubis-uterine fundus distance at rest and during the Valsalva maneuver to define UP in a multicenter study. METHODS: This prospective multicenter observational study included 94 patients (UP =51; CE without UP =43). The clinical examination was based on the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system for assessing pelvic organ prolapse (POP) and patients were candidates for corrective surgery of the middle compartment of the pelvic floor (correction of UP or CE without UP). The ultrasound study was performed by transperineal ultrasound (B-mode) with the patient undergoing dorsal lithotomy. The distance evaluation was performed in relation to the posteroinferior pubic margin in the midsagittal plane, with reference to the uterine fundus (established as the most distal hyperechogenic) line from the pubis to the uterine fundus at rest and with the Valsalva maneuver. We defined UP detected using UP as a difference of ≥15 mm between the pubis-uterine fundus distance at rest and with the Valsalva maneuver. Agreement between the clinical and ultrasound diagnosis of UP was assessed using the Cohen kappa coefficient of agreement and its 95% CIs. RESULTS: The ultrasound diagnosis of global UP at the three centers showed very good agreement, with a kappa index of 0.826 (0.71, 0.94). The agreement of ultrasound with the clinical diagnosis of UP using the ICS POP-Q system was very good for each of the hospitals [Hospital 1: 0.814 (0.64, 0.98), Hospital 2: 0.847 (0.64, 1) and Hospital 3: 0.824 (0.59, 1)]. CONCLUSIONS: A difference of ≥15 mm between the pubis-uterine fundus distance at rest and during the Valsalva maneuver for the diagnosis of UP presents very good agreement with the results of clinical evaluation with the ICS POP-Q system.

In Vitro Study of Preload Loss in Different Implant Abutment Connection Designs.

The stability and integrity of the abutment-implant connection, by means of a screw, is fallible from the moment the prosthetic elements are joined and is dependent on the applied preload, wear of the components and function. One of the main causes of screw loosening is the loss of preload. The loosening of the screw-abutment can cause complications such as screw fracture, marginal gap, peri-implantitis, bacterial microleakage, loosening of the crown and discomfort of the patient. It is also reported that loosening of the screw/abutment may lead to a failure of osseointegration. It is necessary to evaluate and quantify, with in vitro studies, the torque loss before and after loading in the different connections. Aim: evaluate the influence of implant- abutment connection design in torque maintenance after single tightening, multiple tightening and multiple tightening followed by mechanical cycling. Materials and Methods: 180 Klockner implants divided in 4 groups: 15 SK2 external connection, 25 Ncm tightening torque; 15 KL external connection, 30 Ncm tightening torque; 15 Vega internal connection, 25 Ncm tightening torque; 15 Essential internal connection, 30 Ncm tightening torque. In each group removal torque values (RTV) were evaluated with a digital torque meter, in 3 distinct phases: after one single tightening, 10 multiple tightenings and 10 multiple tightenings and cyclic loading (500 N × 1000 cycles). Results: After one single tightening, and for all connections, RTV were lower than those of insertion, but only for Essential and Vega internal connections this result was statistically significant. After multiple tightening, RTV were significantly lower in all connections. After repeated tightening followed by cyclic loading, mean RTV were significantly lower, when compared to insertion torque. The multiple tightening technique resulted in higher RTV than the single tightening technique, except for Vega implant. The multiple tightening followed by cyclic load, compared to the other phases, was the one that generated the lowest RTV, for all connections. Conclusions: The connection design, in our study, did not seem to influence the maintenance of preload. Loading influenced the loss of preload, in the sense that significantly decreased the removal torque values. The multiple re-tightening technique resulted in higher removal torque values than the single tightening technique. Clinically, our results recommend to retighten retaining screws, a few minutes after insertion.

Identification of Pelvic Congestion Syndrome Using Transvaginal Ultrasonography. A Useful Tool.

The gold standard for the diagnosis of pelvic congestion syndrome (PCS) is venography (VG), although transvaginal ultrasound (TVU) might be a noninvasive, nonionizing alternative. Our aim is to determine whether TVU is an accurate and comparable diagnostic tool for PCS. An observational prospective study including 67 patients was carried out. A TVU was performed on patients, measuring pelvic venous vessels parameters. Subsequentially, a VG was performed, and results were compared for the test calibration of TVU. Out of the 67 patients included, only 51 completed the study and were distributed in two groups according to VG results: 39 patients belonging to the PCS group and 12 to the normal group. PCS patients had a larger venous plexus diameter (15.1 mm vs. 12 mm; p = 0.009) and higher rates of crossing veins in the myometrium (74.35% vs. 33.3%; p = 0.009), reverse or altered flow during Valsalva (58.9% vs. 25%; p = 0.04), and largest pelvic vein ≥ 8 mm (92.3% vs. 25%). The sensitivity and specificity of TVU were 92.3% (95% CI: 78.03-97.99%) and 75% (95% CI: 42.84-93.31%), respectively. In conclusion, transvaginal ultrasonography, with the described methodology, appears to be a promising tool for the diagnosis of PCS, with acceptable sensitivity and specificity.

Interobserver variability of ultrasound measurements for the differential diagnosis of uterine prolapse and cervical elongation without uterine prolapse.

OBJECTIVES: Our study aims to determine the interobserver variability of different ultrasound measurements (pubis-cervix distance, pubis-uterine fundus distance, and pubis-Douglascul-de-sac distance) previously analyzed for the ultrasound differential diagnosis of uterine prolapse (UP) and cervical elongation CE without UP. MATERIALS AND METHODS: We conducted a prospective observational study with 40 patients scheduled to undergo surgical correction of UP and CE without UP. All patients underwent pelvic floor ultrasound examination by an examiner (E1) who acquired ultrasound images. Using these images, E1 measured the distances for the ultrasound differential diagnosis of UP and CE without UP, and these distances were compared with those measured by the other examiner (E2). Values were analyzed by calculating ICCs with 95% CIs. RESULTS: For UP, excellent reliability was obtained for all measurements except the pubis-Douglascul-de-sac measurement at rest, which was moderate (ICC 0.596; p = 0.028) and for the difference between the pubis-Douglascul-de-sac measurement at rest and during the Valsalva maneuver, which was good (ICC 0.691; p < 0.0005). For CE without UP, interobserver reliability was excellent for all measurements analyzed except the pubis-cervix measurement during the Valsalva maneuver, which was moderate (ICC 0.535; p = 0.052) and for the pubis-Douglascul-de-sac measurement at rest, which was good (ICC 0.768; p < 0.0005). CONCLUSIONS: There is excellent interobserver reliability in measurements of the difference in the distance from the pubic symphysis to the uterine fundus at rest and during the Valsalva maneuver for both UP and CE without UP, which are used for the ultrasound differential diagnosis of UP and CE without UP.

Evaluation of Pre-malignant Lesions of the Uterine Cervix by Shear Wave Elastography: A New Diagnostic Tool.

The objective of the study was to evaluate the difference in the stiffness between a healthy cervix (no pre-invasive lesions [NPILs]) and a cervix with a pre-invasive lesion (PIL). In the PIL group, we determined whether there was a difference in stiffness between the cervix with persistent low-grade lesions (>2 y, LSIL-persistent) and that with high-grade lesions (HSILs). Evaluation was performed using 2-D shear-wave elastography (SWE) in the midsagittal-plane of the uterine cervix (UC) at 0.5 cm (cervical canal, anterior and posterior cervical lips). In this prospective observational study (consecutive series), we evaluated 96 non-pregnant women: a group with PIL (LSIL-persistent, 22 cases; HSIL, 26 cases) with indications for cervical conization (48 cases) and a group without UC pathology (NPIL, 48 cases). Although we did not observe statistically significant differences (SSDs) in epidemiological characteristics, we did find an SSD in the speed and stiffness between the PIL versus NPIL groups at all evaluated depths (speed: 4.1 m/s vs 3.0 m/s, stiffness: 58.6 and 34.5kPa in the PIL and NPIL groups, respectively, p < 0.001). An SSD in speed and stiffness (speed: 4.9 m/s vs. 3.2 m/s, and stiffness: 76.1 and 38.0 kPa) between the HSIL (26 cases) and LSIL-persistent (22 cases) groups, respectively, was also detected (p < 0.001). The area under the curve of speed differentiation between a cervix with HSILs and without lesions was 73.4% (95% confidence interval [CI]: 63.1-83.7), and the best cutoff of speed was 3.25 m/s (sensitivity = 62.5%, 95% CI: 47.3-76.0), with a specificity of 75.5% (95% CI: 60.4-87.1).

Adverse Health Effects in Women Farmers Indirectly Exposed to Pesticides.

Farmers are among the most vulnerable populations because of the exposure to low levels of pesticides. Acetylcholinesterase and butyrylcholinesterase activities are considered as biomarkers of pesticides poisoning. However, biomarkers of oxidative stress are also playing an important role in toxicity of these contaminants. Further, increased activities of gamma-glutamyltransferase, alanine aminotransferase, urea and creatinine have been linked with hepatic and nephrotoxic cell damage, respectively. The aim of this study was to ascertain if the indirect exposure to pesticides leads to some biochemical parameter changes. Thus, cholinesterase activities, oxidative stress status (lipid and protein oxidation), hepatic function (AST and ALT levels), hormonal function (TSH, T4, FSH, LH and AMH), renal function (serum creatinine and urea), as well as possible subclinical kidney damage (urinary proteins and biomarkers of early kidney damage) were evaluated in farmer women who collect fruits and vegetables comparing with a group of women non-occupational exposed to pesticides but living in the same rural environment. Samples were taken periodically along one year to relate the observed effects to a chronic exposure. Our main results showed for the first time a subclinical kidney damage in a rural setting with indirect chronic exposure to pesticides.

Complications in the Use of Deepithelialized Free Gingival Graft vs. Connective Tissue Graft: A One-Year Randomized Clinical Trial.

In the treatment of gingival recession, different surgical options have been described: free gingival grafts (FGG), connective tissue Grafts (CTG), and a more recent technique, de-epithelialized free gingival graft (DFGG). They are not procedures exempt from the appearance of complications. Most publications refer to postoperative complications, and there is limited literature regarding the development of late complications (weeks or months). Our working group carried out a study to describe the development of late complications associated with the use of DFGG in comparison with CTG, providing an incidence rate and a classification. Sixty-eight patients with mucogingival problems were selected, and divided into two groups: the Test Group, for which we used DFGG + Coronal Advancement Flap (CAF), and the Control Group (CTG + CAF). All patients were treated at the University of Seville's dental school to solve mucogingival problems for aesthetic and/or functional reasons. A classification is proposed based on its severity; Major and Minor. Major complications included reepithelialization of the graft, epithelial bands, cul-de-sac, epithelial cysts, and bone exostoses. Minor complications included the graft´s color changes and superficial revascularization. Late major complications were only associated with the use of the DFGG, and the late minor complications developed with the use of the DFGG were much higher than those associated with CTG. CTG appears to be a safer procedure than DFGG in terms of late complications.