Magnetic Resonance Angiography Alone Is Insufficient for Diagnosis and Surgical Planning in Children With Moyamoya.

BACKGROUND: The gold standard for evaluation of the severity of moyamoya vasculopathy is the Suzuki grade determined with cerebral catheter angiography (CA). With greater use of magnetic resonance angiography (MRA) it is important to understand if MRA is truly comparable to CA. METHODS: Children with moyamoya were evaluated using the Suzuki score for CA and the modified MRA six-stage Suzuki score to describe the angiographic findings in moyamoya from initial narrowing of the distal internal carotid artery to the "puff of smoke" appearance of the lenticulostriate collaterals and finally to the disappearance of this network of collaterals. Using Cohen kappa we compared Suzuki grade based on CA with MRA in the same patients. RESULTS: A total of 27 children with moyamoya were reviewed. We calculated a weighted Cohen kappa of 0.49 (P < 0.0001), which is a moderate correlation. CONCLUSIONS: We suggest caution in the reliance on MRA for the diagnosis and evaluation of severity of moyamoya in children.

Pregnancy outcomes after superovulation-intrauterine insemination (SO-IUI) using gonadotropins versus letrozole in the obese population.

PURPOSE: To compare fertility outcomes of obese patients (body mass index [BMI] ≥ 30 kg/m2) undergoing superovulation and intrauterine insemination (SO-IUI) using gonadotropins versus letrozole. METHODS: A single centre retrospective cohort study of obese patients undergoing SO-IUI using gonadotropins or letrozole between January/2019 and June/2022. Primary outcome was clinical pregnancy rate (intrauterine pregnancy with positive fetal heart rate). Secondary outcomes included rates of multifollicular development, multiple pregnancy, spontaneous abortion and cycle cancellation. Subgroup analysis was done stratifying by obesity class. A multivariate logistic regression model was used for primary/secondary outcomes, adjusting for clinically determined covariates. RESULTS: Out of 802 total identified SO-IUI cycles, 715 cycles were completed (518-gonadotropins and 197-letrozole cycles). The clinical pregnancy rates were not significantly different in obese patients undergoing SO-IUI with gonadotropins versus letrozole when adjusted for age, gravidity, parity, cause of infertility, IUI cycle number, endometrial thickness, sperm source and post-wash motile sperm count (adjusted odds ratio [aOR] 1.37, 95% confidence interval [CI] 0.72-2.59). Similarly, no significant associations were found in spontaneous abortion (aOR1.46, 95%CI 0.42-5.08), multiple pregnancy (aOR1.33, 95%CI 0.20-8.88) or cancellation rates (OR0.89, 95%CI 0.55-1.45) between the two groups. The rates of multifollicular development were also comparable between the two groups (aOR0.51, 95% CI 0.19-1.38). For cycles involving gonadotropins, higher BMI classes required higher total gonadotropin dose (p < 0.001). CONCLUSION: After adjusting for patient and cycle factors, gonadotropins and letrozole led to comparable odds of achieving pregnancy in obese patients undergoing SO-IUI. Future research in the obese population will help to better understand how to optimize fertility treatments for this growing population.

Autism Spectrum Disorder in Children With Perinatal Ischemic Stroke Varies by Stroke Type.

Background and Objectives: Perinatal stroke leads to significant morbidity over a child's lifetime, including diagnosis of various neurodevelopmental disorders. Specific studies examining the prevalence of autism spectrum disorder in children with perinatal stroke are scarce. Following the clinical observation of autism spectrum disorder in a pediatric referral stroke center, we evaluated the rate of autism spectrum disorder diagnosis after perinatal ischemic stroke, including analysis by subtypes of perinatal ischemic stroke. Methods: We retrospectively examined all children diagnosed with perinatal ischemic stroke, who were ≥18 months old at the time of last follow-up at a single institution from 2008 through 2021. We classified patients as having autism spectrum disorder if they were diagnosed by a neurologist, neuropsychologist, clinical psychologist, or developmental pediatrician. Multivariable logistic regression was performed to examine the association between ischemic stroke subtype and autism spectrum disorder. Results: Among 260 children with perinatal stroke, 19 children (7.3%) also had autism spectrum disorder. Children with perinatal venous stroke had 3-fold higher odds of autism spectrum disorder compared to those with perinatal arterial ischemic stroke (adjusted odds ratio: 3.01, 95% confidence interval: 1.07-8.47). Conclusion: In our perinatal ischemic stroke population, children with venous stroke had higher odds of autism spectrum disorder compared to those with arterial ischemic stroke alone. Prospective studies are needed to further investigate the role of perinatal stroke in autism spectrum disorder development.

Comparative Embryo Development Outcomes following Extending Embryo Culture to Day 6: A Retrospective Cohort Study.

BACKGROUND: Past studies have shown that culturing slow-growing embryos from day 5 to day 6 may increase vitrification yield. This study aims to evaluate if the proportion of embryos eligible for vitrification increases by growing embryos not vitrified by day 5 to day 6. MATERIALS AND METHODS: In this retrospective cohort study, a Canadian tertiary-care clinic-based cohort was identified between August 2019 and December 2020. In vitro fertilization (IVF) cycles involving autologous oocytes with at least one viable day 5 embryo were selected for inclusion. We compared embryo developmental outcomes of IVF cycles performed before and after an embryo cryopreservation policy change. Prior to March 2020, good-quality day 5 blastocysts of any stage were eligible for vitrification, and after that date, good-quality expanded blastocysts on either day 5 or day 6 were eligible. The primary outcome is the comparative proportion of embryos eligible for vitrification. The secondary outcome is to identify embryo, maternal and cycle factors that are predictive of day 6 vitrification. RESULTS: A total of 3,438 viable embryos across 679 consecutive IVF cycles were included in this study. After the policy change, we found similar mean proportions of blastocysts eligible for cryopreservation (46.9% per IVF cycle in group 2 vs. 44.4% in group 1, mean difference 0.025, 95% confidence interval -0.021 to 0.071, P=0.28). The mean number of cryopreserved embryos were significantly higher in group 2 (mean 2.2 vs. 1.7 embryos, P=0.007). Factors that predicated an embryo's progression to day 6 included: younger age of egg provider, presence of an early blastocyst on day 5, and cycles involving surgically-retrieved sperm. CONCLUSION: A cryopreservation policy change to include good-quality full and expanded day 6 blastocysts while avoiding to vitrify early blastocysts on day 5 yielded comparable proportions of embryos eligible for vitrification per IVF cycle.

Time-lapse KIDScoreD5 for prediction of embryo pregnancy potential in fresh and vitrified-warmed single-embryo transfers.

RESEARCH QUESTION: Can KIDScoreD5 predict which blastocysts have the highest potential for achieving pregnancy? DESIGN: A retrospective cohort study of 670 single fresh or frozen (FET) embryo transfer cycles was conducted between May 2019 and June 2021 at the Ottawa Fertility Centre, Canada. Blastocysts obtained from stimulated eligible cycles and cultured in a time-lapse incubator were selected for transfer or cryopreservation based on Gardner morphological scoring. Implantation and viable pregnancy rates were analysed retrospectively using KIDScoreD5 and Gardner scores associated with the transferred embryos. The predictive power of the KIDScoreD5 and Gardner assessment was evaluated using the average area under the curve (AUC) of the receiver operating characteristic curve. RESULTS: KIDScoreD5 was positively correlated with implantation (r = 0.96, P = 0.002) and viable pregnancy (r = 0.96, P  = 0.0001) rates. In fresh embryo transfer cycles, the AUC for implantation rate was significantly higher for KIDScoreD5 compared with Gardner scoring (0.70 versus 0.63, P  = 0.03). For FET, significantly higher AUC were calculated for KIDScoreD5 than for Gardner scoring, for both implantation (0.64 versus 0.54, P  = 0.002) and viable pregnancy (0.63 versus 0.53, P  = 0.002) rates. When the ranking of cryopreserved embryos was based on KIDScoreD5, 46.2% of the FET cycles had at least one unused sibling embryo with a better KIDScoreD5 than the one selected for FET based on Gardner assessment. CONCLUSIONS: KIDScoreD5 predicts implantation and viable pregnancy rates of blastocysts better than Gardner morphological assessment in single fresh or cryopreserved embryo transfer cycles.

Preterm birth after recurrent pregnancy loss: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the impact of recurrent pregnancy loss (RPL) on the risk of preterm birth (PTB) in subsequent pregnancies. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Pregnant women with and without a history of RPL. INTERVENTION(S): PubMed, Embase, Google Scholar and Cochrane trial registry were used to identify relevant studies. MAIN OUTCOME MEASURE(S): The odds ratios (ORs) for the association between RPL and PTB across included studies were evaluated. Effect estimates were pooled using a DerSimonian and Laird random-effects meta-analysis model. RESULT(S): Eighteen studies met the inclusion criteria. A total of 58,766 women with a history of RPL and 2,949,222 women without a history of RPL were included. A pooled OR of 1.60 (95% confidence interval [CI], 1.45-1.78; 18 observational studies; I2 = 85.6%) was observed in our random-effects meta-analysis. A trend toward higher odds of PTB is observed with the increasing number of pregnancy losses: 2 RPLs (pooled OR, 1.31; 95% CI, 1.09-1.57; I2 = 88.9%); ≥2 RPLs (pooled OR, 1.58; 95% CI, 1.27-1.96; I2 = 71.7%); and ≥3 RPLs (pooled OR, 1.81; 95% CI, 1.58-2.07; I2 = 73.6%). The analysis of the risk of PTB for patients with unexplained RPL demonstrated a significantly heightened risk of PTB in this subgroup (pooled OR, 2.05; 95% CI, 1.46-2.89; I2 = 21.0%). Inconsistent adjustment for confounders and significant between-study heterogeneity were noted in this study. CONCLUSION(S): Despite significant heterogeneity among studies, we found that women with a history of RPL had significantly higher odds of delivering preterm infants in subsequent pregnancies. CLINICAL TRIAL REGISTRATION NUMBER: CRD 224763.

Building the barricade-DIY slit lamp breath shield.

Ophthalmologists were concerned about the risk of SARS-COV-2 transmission via droplets given the close proximity to the patient during slit lamp examination. There is a need to design a simple, low-cost, waterproof breath shield to minimise risk of infection.Dimensions of the Haag-Streit slit lamp (model BM 900) were recorded to guide accurate design of the breath shield. A questionnaire was circulated among slit lamp users on their perceived risk and concern about SARS-CoV-2 transmission and their perception of how effective different designs of breath shields would be at protecting them from an infection. A number of breath shield prototypes were designed and trialled. Plan, Do, Study, Act (PDSA) cycles were used to improve the design. Materials used to create the breath shields included transparent A3 laminating pouches and laminator, two sheets of A4 paper, scissors, hole punch and a ruler. The breath shield was designed to fit over the objective lens on the slit lamp after temporarily removing the standard, manufacturer-provided breath shield, before replacing it. The breath shields were cleaned after every patient with alcohol wipes and removed for deep cleaning with hand soap and water after each session. We used a proof of concept experiment using fluorescein instilled spray to test the effectiveness of each breath shield at preventing droplet transmission to the slit lamp user.Following four PDSA cycles, a breath shield that is user-friendly, easy to clean was produced. The percentage of confidence that the final design would be effective at preventing droplet transmission increased from 5.6% to 80%.Implementation of a low cost, simple to make, transparent, waterproof breath shield together with other forms of person protective equipment (PPE) creates a safe working environment for clinicians and patients. This intervention can be readily replicated and modified for other slit lamp models.

Perceptions of training in gonioscopy.

PURPOSE: To evaluate ophthalmology trainees' perception of their gonioscopy learning experience in the Ophthalmology Specialty Training programme. MATERIALS AND METHODS: A cross-sectional electronic survey was conducted amongst ophthalmology trainees across London Deaneries. The ten questions survey collected parameters, including training grade, previous level of gonioscopy training, confidence in performing the procedure, level of satisfaction with the training formats received, potential barriers and improvements to the training programme. The respondents were also invited to express any additional comments. RESULTS: Fifty-seven complete responses were analysed. The respondents included 25 junior trainees (ST1-3) and 32 senior trainees (ST4-7 and fellows). One-fifth of the respondents (11/57) were unconfident in performing gonioscopy, the majority being junior trainees (9/11). Over a quarter of the respondents were dissatisfied with the quantity of the gonioscopy training received. Teaching formats, such as consultant teaching (mean 8.0 ± 0.50), self-directed learning (mean 8.0 ± 0.38) and small-group tutorials (mean 7.6 ± 1.6) were all well received. Overall, lack of clinical time was considered as the major barrier to gonioscopy training; however, lack of training was considered as the major barrier in the low-confidence group. CONCLUSIONS: This study highlighted ophthalmology trainees' dissatisfaction in the current gonioscopy training curriculum and a lack of confidence in performing the procedure. Appropriate modifications to the Ophthalmology Specialty Training programme could enhance trainees' gonioscopy learning experience.

Correction: How do paper and electronic records compare for completeness? A three centre study.

Following the publication of the above article the authors noted an error in the author list, 2 authors were mistakenly omitted. Zena Rodrigues and Faisal Ahmed have now been added to the author list and the PDF and HTML versions of the paper have been corrected.

Live Birth Rate after Surgical and Expectant Management of Endometriomas after In Vitro Fertilization: A Systematic Review, Meta-Analysis, and Critical Appraisal of Current Guidelines and Previous Meta-Analyses.

Controversy exists regarding surgical management of endometriomas in infertile women before in vitro fertilization (IVF) because growing evidence indicates that surgery may impair the ovarian response. The objective of the present systematic review and meta-analysis was to compare surgical and expectant management of endometriomas regarding IVF outcomes. Prospective and retrospective controlled studies were found via the Cochrane Library, Embase, and MEDLINE databases. Thirteen studies (1 randomized controlled trial and 12 observational studies, N = 2878) were pooled, and similar live birth rates were observed in the surgically and expectantly managed groups (odds ratio = 0.83; 95% confidence interval [CI], 0.56-1.22; p = .98). The clinical pregnancy rates (odds ratio = 0.83; 95% CI, 0.66-1.05; p = .86), the number of mature oocytes retrieved, and the miscarriage rates were not statistically different between study groups. However, the total number of oocytes retrieved was lower in the surgery group (mean difference = -1.51; 95% CI, -2.60 to -0.43; p = .02). Findings suggest that surgical management of endometriomas before IVF therapy yields similar live birth rates as expectant management. However, future properly designed randomized controlled trials are warranted.

Occult Leiomyosarcomas in a Canadian Province: A Retrospective Cohort Study.

OBJECTIVE: The risk of unexpected uterine leiomyosarcoma (LMS) following surgery for presumed benign leiomyoma is quoted to be between 1 in 498 and 1 in 5000. The objectives of the present study were to determine the prevalence of uterine LMS in a specific patient population and the rate of diagnosis of occult uterine LMS and to evaluate the risk of unintended morcellation of LMS in Saskatchewan. METHODS: This study was a Canadian Task Force Classification II-2 multicentre retrospective cohort study in academic-affiliated tertiary care centres. All women with the histopathologic diagnosis of uterine LMS in Saskatchewan between January 2000 and December 2014 were included. Women with metastatic LMS at diagnosis or other types of uterine sarcomas were excluded. Data including patients' characteristics, clinical presentation, physical examination findings, imaging, pathology reports, surgical interventions, and survival outcomes were reviewed. RESULTS: A total of 28 patients had a confirmed histopathologic diagnosis of LMS over the 15-year study period. Approximately 26 212 hysterectomies were performed in Saskatchewan over the same time frame. The prevalence of uterine LMS in this patient population over the study time frame is estimated to be one in 853. Mean age at diagnosis was 53.8 ± 10.0. Medical records of 25 patients could be retrieved, and 15 cases (60%) had an occult diagnosis. There were five cases of unintended morcellation (one power, four mechanical). Survival outcomes were comparable in women with unintended morcellation of occult disease and in those without morcellation. CONCLUSION: This study contributes to the existing body of literature on morcellation of occult LMS, and it ascertains the rate of LMS in a patient population. The results of this study provide valuable information to health care professionals, policy makers, and women in Saskatchewan so that they may make more informed decisions concerning uterine masses.

Uterine artery pseudoaneurysm with an anastomotic feeding vessel requiring repeat embolisation.

Uterine artery pseudoaneurysm (UAP) is a rare cause of delayed postpartum haemorrhage. Early diagnosis and endovascular management are effective in treating this condition. We present the case of a 36-year-old gravida 3, para 2 woman with delayed postpartum haemorrhage and endometritis following a spontaneous vaginal delivery. Ultrasound and catheter angiogram demonstrated a UAP arising from the distal aspect of the left uterine artery. Significant bleed persisted despite selective bilateral uterine artery embolisation. A repeat angiogram confirmed complete occlusion of bilateral uterine arteries, but abdominal aortogram demonstrated that the left ovarian artery was now feeding the pseudoaneurysm. A repeat embolisation procedure was performed to occlude the left ovarian artery. The patient was discharged the following day. Selective arterial embolisation is effective in the management of UAP. Persistent bleeding despite embolisation should raise the suspicion of anastomotic vascular supply and may require repeat embolisation.

How do paper and electronic records compare for completeness? A three centre study.

OBJECTIVES: Medical records are legal documentation of patients' care hence must be accurate and complete for both medical and legal purposes. Electronic patient record (EPR) systems aim to improve the accuracy of documentation, provide better organisation and access of data. This study compares the completeness of traditional note records and EPR in glaucoma patients. METHODS: Using criteria from the April 2009 National Institute for Health and Care Excellence (NICE) guidelines completeness of data entry was compared between EPR and paper notes in three units. Moorfields Eye Hospital (City Road) uses the Openeyes EPR. Bedford Hospital (Moorfields Eye Centre) and Western Eye Hospital use the Medisoft EPR. The standard was set at 100% compliance for predetermined parameters. RESULTS: One hundred seventy paper notes and 270 electronic records were analysed. With the exception of central corneal thickness (p = 0.31), all other key parameters were more consistently recorded in the paper records than in the EPR. Intraocular pressure (p = 0.004), anterior chamber configuration and depth assessments using gonioscopy (p < 0.001), fundus examination (p = 0.015), past medical history (p < 0.001), medication including glaucoma medication (p < 0.001) and drug allergies (p < 0.001). CONCLUSIONS: Our results show that paper records are significantly more complete than EPR. This is the case for two different EPRs and three separate sites. We propose additional training to aid data-collection; improving the design of EPRs by investigating factors such as layout and use of forced choice fields.

Urinary retention and uterine leiomyomas: a case series and systematic review of the literature.

Uterine leiomyomas are underrecognized as a cause of acute urinary retention (AUR) in women. The objective of this study was to present a case series and systematic review of the literature, to elucidate the pathogenesis of leiomyoma-related AUR, and to suggest management strategies. We included patients presenting with AUR and uterine leiomyomas at our institution between January 2011 and December 2013. Further, we systematically searched the Cochrane Library (from 1898 to June 2014), EMBASE (from 1947 to June 2014), and MEDLINE (from 1946 to June 2014) databases according to the PRISMA guidelines. A total of six patients with AUR and leiomyomas presented to our institution. Through the systematic review, another 31 cases of AUR were identified. Combined patient ages ranged from 25 to 75 years. Uterine size ranged from 10 to 22 weeks on physical examination and from 5.5 to 26 cm on imaging. The dominant leiomyoma size ranged from 5.7 to 22.4 cm. Significant risk factors were posterior or fundal leiomyoma position and the presence of a retroverted uterus. Proposed mechanisms for leiomyoma-related AUR include proximal urethra or bladder-neck compression, premenstrual pelvic congestion, vascular steal effect, and compression of pudendal or sacral nerves. Patients were treated with hysterectomy, myomectomy, uterine fibroid embolization, hormones, or by conservative management alone. In the absence of neurologic disorders or other risk factors, neither urodynamic studies nor neuromuscular testing seem to contribute to diagnosis or guide management in women with uterine leiomyomas and AUR. Patients presenting to gynecologists seem to experience shorter times to diagnosis and treatment compared with other specialties. It is essential to recognize leiomyomas as a potential cause of AUR in order to reduce unnecessary testing and delays in diagnosis and management.