Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020: A joint guideline by the Association of Anaesthetists and the Obstetric Anaesthetists' Association.

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.

Morphometric multislice computed tomography examination of the craniovertebral junction in neck flexion and extension.

BACKGROUND: Detailed study of the craniovertebral junction (CVJ) is necessary to completely understand the mechanism of its flexion and extension. MATERIALS AND METHODS: One cadaver head was sectioned in the sagittal plane. Also, in 22 volunteers, examined using the multislice computed tomography (MSCT), 14 parameters and 2 angles were measured in the neutral position, flexion and extension. RESULTS: The obtained measurements showed the anterior part of the occiput to move inferiorly in flexion, and the anterior atlas arch and the tip of the dens to get closer to the basion. At the same time, the opisthion moves superiorly, but the cervical spine bends anteriorly. Consequently, the dens-opisthion diameter and the opisthion-posterior atlas arch distance slightly decrease in length, whilst the arches of the atlas (C1), axis (C2) and C3 vertebra become more distant. Following extension, the posterior part of the occiput moves inferiorly, so that the basion-dens tip, the basion-axis arch, and the basion-posterior atlas arch distances increase in length. In contrast, the distances of the C1-C3 arches decrease in length. The angle between the foramen magnum and the dens tip decreases 1.620 on average in flexion, but increases 3.230 on average in extension. The angle between the axis body and the opisthion also decreases in flexion (mean, 3.360) and increases in extension (mean, 6.570). Among the congenital anomalies, a partial agenesis of the posterior atlas arch was revealed (4.5%), as well as an anterior dehiscence of the C1 foramen transversarium (13.6%). CONCLUSIONS: The mentioned measurements improved our understanding of the CVJ biomechanics. The obtained data can be useful in the evaluation of the CVJ instability caused by trauma, congenital anomalies and certain spine diseases.

"She was there all the time". A qualitative study exploring how women at higher risk for preterm birth experience midwifery continuity of care.

PROBLEM: There is a paucity of research on experiences and views of women at higher risk of preterm birth of midwifery continuity of care. BACKGROUND: Midwifery continuity of care (MCoC) has been associated with improved maternal outcomes and with lower levels of preterm births and stillbirths. The majority of MCoC studies have focused on women without risk factors and little has been published on women with obstetric complexities. The aim of this study is to explore the views and experiences of women identified as a higher risk of preterm birth who have had continuity of care from midwives. DESIGN: Face-to-face, semi-structured interviews with 16 women identified as at increased risk of preterm birth and experienced continuity of midwifery care across pregnancy, birth and the postnatal period. Care had been provided by the pilot intervention group for the pilot study of midwifery practice in preterm birth including women's experiences (POPPIE) trial. FINDINGS: Women valued continuity of midwifery care across the care pathway and described the reassurance provided by having 24 h a day, seven days a week access to known midwives. Consistency of care, advocacy and accessibility to the team were described as the main factors contributing to their feelings of safety and control. KEY CONCLUSIONS: Recognising that known midwives were 'there all the time' made women feel listened to and actively involved in clinical decision making, which contributed to women feeling less stressed and anxious during their pregnancy, birth and early parenthood. When developing MCoC models for women with obstetric complexities: access, advocacy and time should be embedded to ensure women can build trusting relationships and reduce anxiety levels.

POPPIE: protocol for a randomised controlled pilot trial of continuity of midwifery care for women at increased risk of preterm birth.

BACKGROUND: High rates of preterm births remain a UK public health concern. Preterm birth is a major determinant of adverse infant and longer-term outcomes, including survival, quality of life, psychosocial effects on the family and health care costs. We aim to test whether a model of care combining continuity of midwife care with rapid referral to a specialist obstetric clinic throughout pregnancy, intrapartum and the postpartum period is feasible and improves experience and outcomes for women at increased risk of preterm birth. METHODS: This pilot, hybrid, type 2 randomised controlled implementation trial will recruit 350 pregnant women at increased risk of preterm birth to a midwifery continuity of care intervention or standard care. The intervention will be provided from recruitment (antenatal), labour, birth and the postnatal period, in hospital and community settings and in collaboration with specialist obstetric clinic care, when required. Standard care will be the current maternity care provision by NHS midwives and obstetricians at the study site. Participants will be followed up until 6-8 weeks postpartum. The composite primary outcome is the appropriate initiation of any specified interventions related to the prevention and/or management of preterm labour and birth. Secondary outcomes are related to: recruitment and attrition rates; implementation; acceptability to women, health care professionals and stakeholders; health in pregnancy and other complications; intrapartum outcomes; maternal and neonatal postnatal outcomes; psycho-social health; quality of care; women's experiences and health economic analysis. The trial has 80% power to detect a 15% increase in the rate of appropriate interventions (40 to 55%). The analysis will be by 'intention to treat' analysis. DISCUSSION: Little is known about the underlying reasons why and how models of midwifery continuity of care are associated with fewer preterm births, better maternal and infant outcomes and more positive experiences; nor how these models of care can be implemented successfully in the health services. This will be the first study to provide direct evidence regarding the effectiveness, implementation and evaluation of a midwifery continuity of care model and rapid access to specialist obstetric services for women at increased risk of preterm birth. TRIAL REGISTRATION: ISRCTN37733900 . Retrospectively registered on 21 August 2017.

The surgical anatomy of the perforating branches of the anterior choroidal artery.

BACKGROUND: The available information about certain microanatomic features of the AChA perforators is incomplete. Precise knowledge of these vessels is necessary to understand the consequences of their occlusion and to safely operate in their region. METHODS: The AChA perforators were microdissected and examined under the stereoscopic microscope in 10 vascular casts and in 20 hemispheres injected with india ink or radiopaque substance. RESULTS: The perforating branches ranged in number from 2 to 9 (mean, 4.6) and in diameter between 90 microm and 600 microm (mean, 317 microm). The most proximal perforator arose 3.2 mm on average caudal to the AChA origin. The most distal (capsulothalamic) perforator varied in size from 200 microm to 610 microm (mean, 431 microm). One or more of the perforators always originated from the AChA (100%), but some of them also from the uncal (33.3%) or parahippocampal branch (10%) of the AChA, either as individual vessels only (70%) or from common trunks (30%). The perforators gave off the peduncular (20%), optic (23.3%), or uncal side branches (26.7%). CONCLUSIONS: Our findings concerning the origin, position, number, size, branching, penetration site, and relationships of the AChA perforators gave the anatomic basis for safe operations in patients with AChA aneurysms or mediobasal limbic epilepsy.

The microsurgical anatomy of the premamillary artery.

The 50 premamillary arteries (PremA), arising from 39 posterior communicating arteries (PCoA), were examined in injected human brains. The PremA, which commonly was single (71.8%) and less frequently double (28.2%), more often arose from the PCoA (97.4% ) than from the posterior cerebralartery (PCA) (2.6%). The PremA ranged between 280 and 780 microm in diameter. It gave off side branches to the hypothalamus (23.1%), optic tract (10.2%), mamillary body (17.9%) and the crus cerebri (35.9%). The anastomoses involving the extracerebral segment of the PremA were present in 35.9% of the cases. They varied in caliber from 50 to 230 microm. The intracerebral segment of the PremA ranged from 280 to 490 microm in diameter. Our study gives a precise anatomic basis for safer operations on the aneurysms of the posterior communicating artery and adjacent vessels.

Ex vivo accuracy of three electronic apex locators: Root ZX, Elements Diagnostic Unit and Apex Locator and ProPex.

AIM: To compare ex vivo the accuracy of three electronic apex locators (EALs): Root ZX, Elements Diagnostic Unit and Apex Locator and ProPex. METHODOLOGY: Electronic working length determination was carried out in 40 extracted teeth using an ex vivo model. After access preparation, a first operator determined the reference length (AL) for each tooth under a 30x stereomicroscope using the apical constriction as the apical landmark. All teeth were then measured with each EAL and the results obtained were compared with the corresponding AL. The AL was subtracted from the electronically determined distance. The measurements exceeding the AL were recorded as positive (long) and the measurements short of the AL were recorded as negative. Data were analyzed using the Friedman Test and Tukey multiple range test for nonparametric correlation amongst groups. Statistical significance was considered at P < 0.05. RESULTS: Comparing the differences between measurements obtained with the three EALs and those obtained with the stereomicroscope, the percentage of measurements within +/-0.5 mm of the AL was 97.37% (84.22% within 0.5 mm short of AL) for the Root ZX, 94.28% (88.57% within 0.5 mm short of AL) for the Elements and 100% (35.9% within 0.5 mm short of AL) for the ProPex. The mean difference between the AL and the lengths measured by the Root ZX, the Elements and the ProPex were, respectively, -0.157 +/- 0.228, -0.103 +/- 0.359 and 0.307 +/- 0.271 mm. CONCLUSIONS: The results of the present study confirm that the EALs determined the canal length within +/-0.5 mm from the apical constriction in the majority of cases. The majority of the ProPex readings were long.

The oculomotor nuclear complex in humans. Microanatomy and clinical significance.

This study has been performed to define better the anatomical structure of the oculomotor nuclear complex and its neuronal components. The oculomotor nuclear complex was examined in fixed and serially sectioned midbrains from 12 adult subjects free from neurological diseases. The complex included the somatic portion, (formed by multipolar motor neurons), and the parasympathetic portion, (formed by oval or fusiform preganglionic cells), on each side of the median raphe. The somatic portion consisted of the lateral somatic cell column and the caudal central nucleus. The somatic column measured from 0.2 x 0.1 mm to 3.4 x 1.4 mm (X = 2.4 x 1.2 mm) in transverse section. It was divided into the principal, intrafascicular and extrafascicular parts. The principal part was subdivided into the dorsal, intermediate and ventral portions. Isolated multipolar neurons were also found in the periaqueductal gray matter, the interstitial nucleus of Cajal, the Edinger-Westphal nucleus and the fibre bundles of the oculomotor nerve. These cells most likely represent the displaced motor neurons of the oculomotor nerve. The caudal central nucleus was 0.8 x 0.6 mm in size. The Edinger-Westphal nucleus consisted of the rostral, ventral and dorsal parts; the longest rostrocaudal diameter of this nucleus measured 7.1 mm. The anatomical data of our study are relevant clinically and allow explanation of the neurologic signs following complete or partial lesions of the oculomotor nuclear complex.

Territories of the perforating (lenticulostriate) branches of the middle cerebral artery.

The territories of the central branches of the middle cerebral artery (MCA) were examined in 21 injected human brains. It was noted that these central arteries supplied: the caudate nucleus (dorsolateral half of the rostral part of its head; the entire caudal part of the head; the body and rostral portion of the tail in some cases), the putamen (dorsolateral part of its rostral portion, the remainder of the putamen, except the most caudal part occasionally), the globus pallidus (the entire lateral segment, except the ventrorostral and, sometimes, the most caudal part), the basal forebrain (lateral parts of the basal nucleus of Meynert and the nucleus of the diagonal band, as well as fiber bundles in this region), the internal capsule (dorsal and ventrocaudal part of the anterior limb, dorsal part of the genu, dorsal and ventrorostral part of the posterior limb), the corona radiata (a narrow strip close to the internal capsule) and the cerebral cortex (the caudal orbitofrontal cortex occasionally). The presented data may have certain neuroradiologic, neurologic and neurosurgical significance.