Right ventricle-specific therapies in acute respiratory distress syndrome: a scoping review.

OBJECTIVE: To summarize knowledge and identify gaps in evidence regarding treatment of right ventricular dysfunction (RVD) in acute respiratory distress syndrome (ARDS). DATA SOURCES: We conducted a comprehensive search of MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION: Studies were included if they reported effects of treatments on right ventricular function, whether or not the intent was to modify right ventricular function. DATA EXTRACTION: Data extraction was performed independently and in duplicate by two authors. Data items included the study design, patient population, type of intervention, comparison group, and RV-specific outcomes. DATA SYNTHESIS: Of 1,430 studies screened, 51 studies reporting on 1,526 patients were included. By frequency, the included studies examined the following interventions: ventilator settings (29.4%), inhaled medications (33.3%), extracorporeal life support (13.7%), intravenous or oral medications (13.7%), and prone positioning (9.8%). The majority of the studies were non-randomized experimental studies (53%), with the next most common being case reports (16%). Only 5.9% of studies were RCTs. In total, 27% of studies were conducted with the goal of modifying RV function. CONCLUSIONS: Given the prevalence of RVD in ARDS and its association with mortality, the dearth of research on this topic is concerning. This review highlights the need for prospective trials aimed at treating RV dysfunction in ARDS.

Caesarean section rates in primigravid women categorised by age and BMI.

The rising caesarean section (CS) rate is a complex issue, particularly in an increasingly heterogenous nulliparous population. The study aim was to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. This was a retrospective review of CS procedures of nulliparous women in two centres in Ireland (2014 through 2017). Data were obtained for 17,177 women from the hospital databases and CS procedures determined for each age and BMI category. Significant differences were observed when CS rates were stratified in this manner. The CS rates for women <20 years/BMI < 18.5 was 8.8 versus 57.6% for women 35 - 39 years/BMI 30 - 34 and 76 - 100% for all women >45 years (p<.005). The development of customised charts subdivided by age and BMI may be a useful counselling tool and assist in the comparison of rates between units.Impact statementWhat is already known on this subject? It is well known that along with rising CS rates globally, there have also been significant changes in maternal demographics-with increasing maternal age at first birth and increasing maternal BMI. It is well established that both of these factors affect the rate of CS in a population.What do the results of this study add? This study sought to stratify the CS rate in nulliparous women by age and BMI to determine if any difference existed. The results of the study showed an increasing CS rate for increasing age and BMI categories that was statistically significant.What are the implications of these findings for clinical practice and/or further research? Additional research using larger population data sets could allow the development of customised charts for nulliparous women subdivided by age and BMI which could act as a useful counselling tool in clinical practice, as well as assist in the comparison of CS rates between units.

Conservative Management of Pelvic Organ Prolapse: Indian Contribution.

Pelvic organ prolapse (POP) is a very common condition which can greatly impact a woman's quality of life. Treatment options are individualized and typically involve a combination of physiotherapy, pessary insertion and surgical treatments. It is well known that nulliparous prolapse in India constitutes 1.5-2% of genital prolapse, while the incidence is even higher (5-8%) for young women who have delivered one or two children, thus making it one of the highest rates in the world. This has necessitated the development of numerous conservative surgical treatment options for POP, which allows women to retain their sexual and reproductive function and therefore allows for subsequent pregnancies. With the controversy surrounding the use of mesh, a variety of surgical treatment options should be considered. Such alternative treatments include the use of surgical sling procedures, which have been used widely in Indian practice for the treatment of POP for over 60 years. This review outlines some of the well-established conservative treatment options for POP. It also highlights the unique contribution of Indian Obstetricians in the development of these conservative surgical treatment options, from prominent Indian Gynecologists including Dr VN Shirodkar, Dr BN Purandare, VN Purandare, RP Soonawala, Brigadier SD Khanna and Dr RM Nadkarni.

Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world.

Cesarean section (CS) is one of the most commonly performed surgical operations in the world and has resulted in improved maternal and neonatal morbidity and mortality rates internationally. However, concerns have been raised regarding the ever increasing CS rates to what has been described as 'epidemic' proportions. Global CS rates have increased from 6.7% in 1990 to 19.1% in 2014. However, there is a vast variation in the CS rates between countries with CS rates of 44.3% reported across Latin America & the Caribbean and CS rates as low as 4.1% in central and West Africa. There is much controversy regarding the optimal figure for CS in a population. The optimal CS rates for a population have been recommend in various studies, ranging from 10% to 19%, above which no reported improvement in maternal and neonatal mortality rates is observed. This review examines the evolution of the changing indications for CS and increasing CS rates in a world where family sizes are reducing and maternal age at first pregnancy is increasing. Efforts must be made to agree on an appropriate classification system whereby CS rates can be compared accurately between units and countries as a useful tool to audit and monitor our practice. Obstetricians should consider the indications for each CS performed, be conscious of the CS rate in our own countries and institutions and most importantly, be cognizant of how the CS rate impacts the maternal and perinatal morbidity and mortality rates and adjust our practice accordingly, to minimize harm.