Phenotypic and genomic characterization of a non-pathogenic Epilithonimonas ginsengisoli isolated from diseased farmed rainbow trout (Oncorhynchus mykiss) in Chile.

Flavobacterial infection associated with diseased fish is caused by multiple bacterial species within the family Flavobacteriaceae. In the present study, the Chilean isolate FP99, from the gills of a diseased, farmed rainbow trout (Oncorhynchus mykiss), was characterized using phenotypic and genomic analyses. Additionally assessed was pathogenic activity. Phylogenetic analysis based on 16S rRNA gene sequencing confirmed that isolate FP99 belonged to the genus Epilithonimonas, an average nucleotide identity value of 100% was detected with the Chilean isolate identified as Epilithonimonas sp. FP211-J200. In silico genome analysis, mechanisms for toxins production, and superantigens, adhesion, or other genes associated with virulence were not detected. However, genes encoding proteins for antibiotic resistance were found, including the chrA gene and the nucleotide sequence that encodes for multiple antibiotic resistance MarC proteins. Furthermore, the blaESP-1 gene (87.85% aminoacidic sequence identity), encoding an extended-spectrum subclass B3 metallo-ß-lactamase and conferring carbapenem-hydrolysing activity, and the tet(X) gene, which encodes a monooxygenase that catalyses the degradation of tetracycline-class antimicrobials were carried by this isolate. Phenotyping analyses also supported assignment as E. ginsengisoli. Challenge trials against healthy rainbow trout resulted in no observed pathogenic effect. Our findings identify for the first time the species E. ginsengisoli as associated with fish farming, suggesting that this isolate may be a component of the microbiota of the freshwater system. Notwithstanding, poor environmental conditions and any stressors associated with aquaculture situations or lesions caused by other pathogenic bacteria, such as F. psychrophilum, could favour the entry of E. ginsengisoli into rainbow trout.

Estudio exploratorio de un taller basado en el Protocolo Unificado para el manejo de ansiedad ante exámenes.

Introducción: La ansiedad ante exámenes es un constructo multidimensional, caracterizado por respuestas fenomenológicas, fisiológicas, conductuales y cognitivas asociadas a una preocupación excesiva sobre posibles consecuencias negativas ante una situación evaluativa. En estudiantes universitarios, presenta tasas de  ocurrencia entre 10 % y 40 %. El objetivo es evaluar la utilidad de un taller grupal y online para el manejo de esta problemática, basado en el Protocolo Unificado. Método: Participaron 31 estudiantes argentinos con edades de 18 a 35 años (M=25; DE= 5,24), siendo el 93.5 % mujeres. Se evaluó medidas pre, post y seguimiento en sintomatología asociada a la ansiedad ante exámenes (GTAI-AR) como variable primaria, y estrategias de regulación emocional (ERQ) y conciencia plena (MAAS) como variables secundarias. Para corroborar diferencias intra grupo se calculó la prueba de Wilcoxon, y como medida de tamaño del efecto (TE), la g de Hedges. Resultados: En cuanto a la variable primaria entre las tres medidas aplicadas, las diferencias fueron significativas con TE moderados y grandes. En las variables secundarias, solo la  reevaluación cognitiva reflejó TE considerables (pequeños) en el pre-post; en el post-seguimiento la supresión expresiva fue la única dimensión que reflejó TE significativos (moderados); y en el pre-seguimiento, únicamente la conciencia plena arrojó TE relevantes (pequeños). Discusión: Los resultados son coherentes con el marco del Protocolo Unificado y las investigaciones actuales sobre su aplicación. Conclusiones: Se espera que estos resultados sean útiles para el diseño de intervenciones similares. Si bien éstos fueron alentadores, se requieren investigaciones de mayor rigurosidad que permitan estudiar su eficacia.

Crassostrea gigas oysters from a non-intensive farming area naturally harbor potentially pathogenic vibrio strains.

Farming intensification and climate change are inevitably linked to pathogen emergence in aquaculture. In this context, infectious diseases associated with vibrios span all developmental stages of the Pacific Oyster Crassostrea gigas. Moreover, virulence factors associated with pathogenicity spread among the vibrio community through horizontal gene transfer as part of the natural eco-evolutive dynamic of this group. Therefore, risk factors associated with the emergence of pathogens should be assessed before the appearance of mass mortalities in developing rearing areas. In this context, we characterized the vibrios community associated with oysters cultured in a non-intensive area free of massive mortalities located at Tongoy bay, Chile, through a culture-dependent approach. We taxonomically affiliated our isolates at the species level through the partial sequencing of the heat shock protein 60 gene and estimated their virulence potential through experimental infection of juvenile C. gigas. The vibrio community belonged almost entirely to the Splendidus clade, with Vibrio lentus being the most abundant species. The virulence potential of selected isolates was highly contrasted with oyster survival ranging between 100 and 30 %. Moreover, different vibrio species affected oyster survival at different rates, for instance V. splendidus TO2_12 produced most mortalities just 24 h after injection, while the V. lentus the most virulent strain TO6_11 produced sustained mortalities reaching 30 % of survival at day 4 after injection. Production of enzymes associated with pathogenicity was detected and hemolytic activity was positive for 50 % of the virulent strains and negative for 90 % of non-virulent strains, representing the phenotype that better relates to the virulence status of strains. Overall, results highlight that virulence is a trait present in the absence of disease expression, and therefore the monitoring of potentially pathogenic groups such as vibrios is essential to anticipate and manage oyster disease emergence in both established and under-development rearing areas.

Towards sustainable management of agricultural resources: A framework to assess the relationship between water, soil, economic factors, and grain production.

As the requirements for environmental protection and high-efficiency economies increase, grain production (GP) across the globe faces more stringent ecological constraints and economic pressure. Understanding the relationships between natural resources and economic and agricultural factors in grain-producing regions is paramount for ensuring global food security. This paper proposes a methodological framework to explore the relationships between water and soil resources (WSRs), economic input factors (EIFs), and GP. We employed the northeast region of China as a case study to advance our understanding of the factors driving the development of grain-producing capacity. We first constructed and calculated the region's water and soil comprehensive index (WSCI) to describe water-soil properties. We then used hotspot analysis to explore the spatial agglomeration characteristics of WSRs, EIFs, and GP. Finally, we used threshold regression analysis to understand the effects of EIFs and GP with the WSCI as the threshold variable. With the improvement of the WSCI, the positive impact of fertilizer and irrigation on GP shows a U-shaped curve in elasticity coefficients. The positive effect of agricultural machinery on GP decreases significantly, and the impact of labor input on GP is insignificant. These results provide new insights into the relationship between WSRs, EIFs, and GP and a reference for improving GP efficiency globally. This work thus contributes to advancing our capabilities to enable food security while considering aspects of sustainable agriculture in important grain-producing regions across the globe.

An extension of the characteristic curve model of plant species behavior in heavy metal soils.

This article proposes a mathematical model to characterize phytoremediation processes in soils contaminated with heavy metals. In particular, the proposed model constructs characteristic curves for the concentrations of several metals (As, Cd, Cu, Fe, Pb, Sb, and Zn) in soils and plants based on the experimental data retrieved from several bibliographical sources comprising 305 vegetal species. The proposed model is an extension of previous models of characteristic curves in phytoremediation processes developed by Lam et al. for root measurements using the bioconcentration factor. However, the proposed model extends this approach to consider roots, as well as aerial parts and shoots of the plant, while at the same time providing a less complex mathematical formula compared to the original. The final model shows an adjusted R2 of 0.712, and all its parameters are considered statistically significant. The model may be used to assess samples from a given plant species to identify its potential as an accumulator in the context of soil phytoremediation processes. Furthermore, a simplified version of the model was constructed using an approximation to provide an easy-to-compute alternative that is valid for concentrations below 37,000 mg/kg. This simplified model shows results similar to the original model for concentrations below this threshold and it uses an adjusted factor defined as [Formula: see text] that must be compared with a threshold depending on the metal, type of measurement, and target (e.g., accumulator or hyperaccumulator). The full model construction shows that 90 out of the 305 species assessed have a potential behavior as accumulators and 10 of them as hyperaccumulators. Finally, out of the 1405 experimental measurements, 1177 were shown to be accumulators or hyperaccumulators. In particular, 85% of the results coincide with the reported values, thus validating the proposed model.

A g-type lysozyme from the scallop Argopecten purpuratus participates in the immune response and in the stability of the hemolymph microbiota.

Lysozymes are antimicrobial acid hydrolases widely distributed in nature. They are located inside the cells in lysosomes, or they are secreted to the extracellular space, where they can lyse the cell wall of certain species of bacteria via hydrolysis of the peptidoglycan. Thus, lysozymes are bacteriolytic enzymes and play a major biological role in biodefense, as these enzymes can act as antibacterial and immune-modulating agents. In this study, we characterized a g-type lysozyme from the scallop Argopecten purpuratus named ApGlys. The cDNA sequence comprises an open reading frame (ORF) of 600 nucleotides, codifying for a putative protein of 200 amino acids with a signal peptide of 18 amino acids. The deduced mature protein sequence displays a molecular weight of 20.07 kDa and an isoelectric point (pI) of 6.49. ApGlys deduced protein sequence exhibits conserved residues associated with catalytic activity and substrate fixation in other g-type lysozymes. The phylogenetic analysis revealed a high degree of identity of ApGlys with other mollusk g-type lysozymes, which form a restricted and separated clade from the vertebrate lysozymes. ApGlys transcripts were constitutively and highly expressed in the digestive gland, and it was induced in hemocytes and gills of scallops after an immune challenge. Furthermore, the ApGlys protein was located inside hemocytes of immunostimulated scallops, determined by immunofluorescence analysis. Finally, the transcript silencing of ApGlys by RNA interference led to an increase of total culturable bacteria from the scallop hemolymph. Furthermore, we detected a higher diversity of the bacterial community in ApGlys-silenced scallops and an imbalance of certain bacterial groups present in the hemolymph by 16S rDNA deep amplicon sequencing. Overall, our results showed that ApGlys is a new member of scallop lysozymes that is implicated in the immune response and in the microbial homeostasis of A. purpuratus hemolymph.

First description outside Europe of the emergent pathogen Vibrio europaeus in shellfish aquaculture.

Vibrio europaeus is an emergent pathogen affecting the most important bivalve species reared in Spanish and French hatcheries. Using a genomic approach, we identified V. europaeus outside Europe for the first time from massive larval mortalities of scallop (Argopecten purpuratus) in Chile and from seawater near a shellfish hatchery in the US West Coast. Results show the worldwide spreading and potential impact of V. europaeus for aquaculture; these four countries are among the 10 major producers of mollusks. Pathogenicity of V. europaeus was demonstrated for the first time towards scallop, the second most important species for Chilean mariculture.

5,926 hysterectomies: complications described by Clavien-Dindo classification.

Hysterectomy is the most common major gynaecological surgery. Due to its high volume, the analysis of its results is relevant. The objective of this study was to describe intraoperative complications and reoperations, for both benign and malignant causes, using the Clavien-Dindo classification (approved by local ethics committee, number 100220). Between 2000 and 2019, 5926 elective hysterectomies were performed, of which 90.2% were for benign aetiology and 9.8% for malignant causes. The abdominal route was 52.7%, vaginal 40.1% and laparoscopic 7.2%. Intraoperative complications and reoperations (grade III Clavien-Dindo) were 4% and 2.1%, respectively. Oncological surgery had significantly more intraoperative complications (10% vs. 3.4%) and reoperations (3.6% vs. 1.9%) than benign procedures. Noteworthy, intraoperative complications required a new operation in only 3.4% for malignant and 2.8% for benign surgery. Our data showed the relevance of detecting and rectifying intraoperative complications during surgery, which consequently leads to a lower reoperation rate, minimising postoperative morbidity and mortality for patients.Impact StatementWhat is already known on this subject? The surgical complications of hysterectomy, both intraoperative and postoperative, are extensively described. However, this information is not well systematised, in which elective and emergency surgery are mixed. In addition to the above, there are few documents comparing the results of hysterectomies due to benign versus malignant causes.What the results of this study add? Using the Clavien-Dindo classification, this study adds an organised description of intraoperative complications and reoperations of hysterectomy in the context of elective surgery. In addition, it provides information on the comparison between surgery for benign versus malignant causes, as well as information on intraoperative complications requiring a new operation.What the implications are of these findings for clinical practice and/or further research? These findings provide clear and orderly data about the risks of elective hysterectomy and showed the relevance of detecting and rectifying intraoperative complications during the procedure. This is useful for specialists to preoperatively identify the risks for each hysterectomy group and provide their patients with more detailed information during informed consent.

Going beyond the curve: Strategic measures to recover hotel activity in times of COVID-19.

Hospitality firms are facing unprecedented challenges on a global scale. The catastrophic effects of the COVID-19 pandemic and its multiple devastating global consequences have initiated a profoundly disruptive transformation in the hospitality sector, as firms attempt to adapt their activity to the current uncertain scenario. This study draws on the crisis management literature to identify the key drivers of hotel recovery in the event of a disaster or an external crisis, like current pandemic. A sample of 237 Spanish hotel managers evaluated and ranked the strategic measures. Based on this evidence, measures were statistically examined to identify which ranked as most significant in helping hospitality managers. The results yield valuable theoretical and practical insights to guide hospitality managers towards business adaptation and recovery by highlighting key strategic measures for implementation in the short term.

Molecular characterization and expression patterns of two LPS binding /bactericidal permeability-increasing proteins (LBP/BPIs) from the scallop Argopecten purpuratus.

Lipopolysaccharide-binding proteins (LBPs) and bactericidal permeability-increasing proteins (BPIs) are effectors of the innate immune response which act in a coordinated manner to bind and neutralize the LPS present in Gram negative bacteria. The structural organization that confers the function of LBPs and BPIs is very similar, however, they are antagonistic to each other. In this work, we characterized two LBP/BPIs from the scallop Argopecten purpuratus, namely ApLBP/BPI1 and ApLBP/BPI2. The molecular and phylogenetic analyses of ApLBP/BPIs indicated that both isoforms display classic characteristics of LBP/BPIs from other invertebrates. Additionally, ApLBP/BPIs are constitutively expressed in scallop tissues and their transcript expression is upregulated in hemocytes and gills in response to an immune challenge. However, some structural characteristics of functional importance for the biological activity of these molecules, such as the net charge differ substantially between ApLBP/BPI1 and ApLBP/BPI2. Furthermore, each isoform displays a specific profile of basal expression among different tissues, as well as specific patterns of expression during the activation of the immune response. Results suggest that functional specialization of ApLBP/BPIs might happen, with potential role as LBP or BPI in this species of scallop. Further research on the biological activities of ApLBP/BPIs are necessary to elucidate their participation in the scallop immune response.

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery.

AIMS: Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery. METHODS: Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis. RESULTS: The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131. CONCLUSIONS: One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.

Genetic and morphological divergence at a biogeographic break in the beach-dwelling brooder Excirolana hirsuticauda Menzies (Crustacea, Peracarida).

BACKGROUND: There is a biogeographic break located at 30°S in the southeast Pacific, in a coastal area of strong environmental discontinuities. Several marine benthic taxa with restricted dispersal have a coincident phylogeographic break at 30°S, indicating that genetic structure is moulded by life history traits that limit gene flow and thereby promote divergence and speciation. In order to evaluate intraspecific divergence at this biogeographic break, we investigated the genetic and morphological variation of the directly developing beach isopod Excirolana hirsuticauda along 1900 km of the southeast Pacific coast, across 30°S. RESULTS: The COI sequences and microsatellite data both identified a strong discontinuity between populations of E. hirsuticauda to the north and south of 30°S, and a second weaker phylogeographic break at approximately 35°S. The three genetic groups were evidenced by different past demographic and genetic diversity signatures, and were also clearly distinguished with microsatellite data clustering. The COI sequences established that the genetic divergence of E. hirsuticauda at 30°S started earlier than divergence at 35°. Additionally, the three groups have different past demographic signatures, with probable demographic expansion occurring earlier in the southern group (south of 35°S), associated with Pleistocene interglacial periods. Interestingly, body length, multivariate morphometric analyses, and the morphology of a fertilization-related morphological character in males, the appendix masculina, reinforced the three genetic groups detected with genetic data. CONCLUSIONS: The degree of divergence of COI sequences, microsatellite data, and morphology was concordant and showed two geographic areas in which divergence was promoted at differing historical periods. Variation in the appendix masculina of males has probably promoted reproductive isolation. This variation together with gene flow restrictions promoted by life history traits, small body size, oceanographic discontinuities and sandy-beach habitat continuity, likely influenced species divergence at 30°S in the southeast Pacific coast. The degree of genetic and morphological differentiation of populations to the north and south of 30°S suggests that E. hirsuticauda harbours intraspecific divergence consistent with reproductive isolation and an advanced stage of speciation. The speciation process within E. hirsuticauda has been shaped by both restrictions to gene flow and a prezygotic reproductive barrier.

Levator ani muscle injury and risk for urinary and fecal incontinence in parous women from a normal population, a cross-sectional study.

AIMS: To study possible associations between levator ani muscle (LAM) injury and urinary incontinence (UI) and fecal incontinence (FI) and possible associations between bladder neck descent (BND), urethral funneling, and UI. METHODS: A cross-sectional study of 608 women with first delivery in 1990 to 1997 assessed in 2013 to 2014. The Urinary Distress Inventory (UDI-6) and Colorectal Anal Distress Inventory (CRADI-8) were used to quantify symptoms (range, 0-100). The proportion of women with UI and FI was calculated. LAM injury, BND ≥25 mm, and funneling were diagnosed with transperineal ultrasound. Women with LAM injury, BND, and urethral funneling were compared to those without, using the Mann-Whitney U test (symptom scores) and multiple logistic regression analysis (UI and FI). RESULTS: Four-hundred ninety-three (81%) women had intact LAM and 113 (19%) had LAM injury. They had similar median (range) UDI-6 score 8.3 (0-75) vs 4.2 (0-62.5), P = .35, and CRADI-8 score 6.3 (0-78.1) vs 6.3 (0-62.5), P = .90. Three hundred eleven out of six hundred (52%) women had UI and 65 of 594 (11%) had FI. This was similar for women with intact vs injured LAM; UI 53% vs 49%, P = .67; FI 11% vs 12%, P = .44 and with and without BND; stress UI 42% vs 42%, P = .93; urge UI 29% vs 35%, P = .34. Stress UI was more common in women with urethral funneling (50% vs 40%), odds ratio 1.56 (95% confidence interval: 1.03-2.37), P = .04. CONCLUSION: We found no associations between LAM injury and symptoms of UI and FI 15 to 24 years after the first delivery, but urethral funneling was associated with stress UI.

Comparison of transperineal ultrasound with POP-Q for assessing symptoms of prolapse.

INTRODUCTION: Our aim was to study any correlation between pelvic organ prolapse quantification (POP-Q) and ultrasound measurement of prolapse in women from a normal population and to identify the method with a stronger association with prolapse symptoms. METHODS: A cross-sectional study of 590 parous women responding to the Pelvic Floor Distress Inventory was carried out. They were examined using POP-Q and transperineal ultrasound, and correlation was tested using Spearman's rank test. Numerical measurements and significant prolapse (POP-Q ≥ 2 in any compartment or bladder ≥10 mm, cervix ≥0 mm or rectal ampulla ≥15 mm below the symphysis on ultrasound) were compared in symptomatic and asymptomatic women (Mann-Whitney U and Chi-squared tests). RESULTS: A total of 256 women had POP-Q ≥ 2 and 209 had significant prolapse on ultrasound. The correlation (rs) between POP-Q and ultrasound was 0.69 (anterior compartment), 0.53 (middle), and 0.39 (posterior), p < 0.01. Women with a "vaginal bulge" (n = 68) had greater descent on POP-Q and ultrasound in the anterior and middle compartments than asymptomatic women, p < 0.01. For women with a symptomatic bulge, the odds ratio was 3.8 (95% CI 2.2-6.7) for POP-Q ≥ grade 2 and 2.4 (95% CI 1.4-3.9) for prolapse on ultrasound. A sensation of heaviness (n = 90) and incomplete bladder emptying (n = 4) were more weakly associated with ultrasound (p = 0.03 and 0.04), and splinting (n = 137) was associated with POP-Q Bp, p = 0.02. CONCLUSION: POP-Q and ultrasound measurement of prolapse had moderate to strong correlation in the anterior and middle compartments and weak correlation in the posterior compartment. Both methods were strongly associated with the symptom "vaginal bulge," but POP-Q had a stronger association than ultrasound.

Voiding symptoms obtained by open versus directed anamnesis as predictors of voiding dysfunction in women.

OBJECTIVES: To determine the differences between voiding symptoms obtained by open anamnesis (VS-Open) versus voiding symptoms obtained by directed anamnesis (VSDirected) to predict voiding dysfunction in women. MATERIALS AND METHODS: Retrospective study of women with prior anti-incontinence surgery evaluated during 5 years. In a standardized clinical history taking, each patient was asked to answer question number fi ve of the UDI-6 questionnaire ("Do you experience any difficulty emptying your bladder?"). If the answer was positive, the following voiding symptoms spontaneously described by the patient were documented: slow urine stream, straining to void, intermittent stream and feeling of incomplete bladder emptying, which were considered VS-Open. If the answer to this question was negative or if the patient had not reported the four voiding symptoms, she was asked in a directed manner about the presence of each of them, which were considered VS-Directed. Voiding dysfunction was considered the presence of a maximum fl ow ≤ 12 mL/s and/ or a postvoid residual > 100 mL. RESULTS: Ninety-one women are analyzed. Eighteen patients presented voiding dysfunction (19.8%), There was a statistical association between voiding dysfunction and the presence of any VS-Open (p = 0.037) and straining to void obtained by open anamnesis (p = 0.013). Sensitivity, specificity, PPV, NPV, positive likelihood ratio and negative likelihood ratio, respectively, were 44.4% and 27.8%, 80.8% and 94.5%, 36.3% and 55.6%, 85.5% and 84.1%, 2.324 and 5.129, and 0.686 and 0.764. There was no statistical association between voiding dysfunction and VS-Directed. CONCLUSIONS: VS-Open may predict better voiding dysfunction than VS-Directed in women.

Atraumatic normal vaginal delivery: how many women get what they want?

BACKGROUND: Trauma to the perineum, levator ani complex, and anal sphincter is common during vaginal childbirth, but often clinically underdiagnosed, and many women are unaware of the potential for long-term damage. OBJECTIVE: In this study we use transperineal ultrasound to identify how many women will achieve a normal vaginal delivery without substantial damage to the levator ani or anal sphincter muscles, and to create a model to predict patient characteristics associated with successful atraumatic normal vaginal delivery. STUDY DESIGN: This is a retrospective, secondary analysis of data sets gathered in the context of an interventional perinatal imaging study. A total of 660 primiparas, carrying an uncomplicated singleton pregnancy, underwent an antepartum and postpartum interview, vaginal exam (Pelvic Organ Prolapse Quantification), and 4-dimensional translabial ultrasound. Ultrasound data were analyzed for levator trauma and/or overdistention and residual sphincter defects. Postprocessing analysis of ultrasound volumes was performed blinded against clinical data and analyzed against obstetric data retrieved from the local maternity database. Levator avulsion was diagnosed if the muscle insertion at the inferior pubic ramus at the plane of minimal hiatal dimensions and within 5 mm above this plane on tomographic ultrasound imaging was abnormal, ie the muscle was disconnected from the inferior pubic ramus. Hiatal overdistensibility (microtrauma) was diagnosed if there was a peripartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2. A sphincter defect was diagnosed if a gap of >30 degrees was seen in ≥4 of 6 tomographic ultrasound imaging slices bracketing the external anal sphincter. Two models were tested: a first model that defines severe pelvic floor trauma as either obstetric anal sphincter injury or levator avulsion, and a second, more conservative model, that also included microtrauma. RESULTS: A total of 504/660 women (76%) returned for postpartum follow-up as described previously. In all, 21 patients were excluded due to inadequate data or intercurrent pregnancy, leaving 483 women for analysis. Model 1 defined nontraumatic vaginal delivery as excluding operative delivery, obstetric anal sphincter injuries, and sonographic evidence of levator avulsion or residual sphincter defect. Model 2 also excluded microtrauma. Of 483 women, 112 (23%) had a cesarean delivery, 103 (21%) had an operative vaginal delivery, and 17 (4%) had a third-/fourth-degree tear, leaving 251 women who could be said to have had a normal vaginal delivery. On ultrasound, in model 1, 27 women (6%) had an avulsion and 31 (6%) had a residual defect, leaving 193/483 (40%) who met the criteria for atraumatic normal vaginal delivery. In model 2, an additional 33 women (7%) had microtrauma, leaving only 160/483 (33%) women who met the criteria for atraumatic normal vaginal delivery. On multivariate analysis, younger age and earlier gestation at time of delivery remained highly significant as predictors of atraumatic normal vaginal delivery in both models, with increased hiatal area on Valsalva also significant in model 2 (all P ≤ .035). CONCLUSION: The prevalence of significant pelvic floor trauma after vaginal child birth is much higher than generally assumed. Rates of obstetric anal sphincter injury are often underestimated and levator avulsion is not included as a consequence of vaginal birth in most obstetric text books. In this study less than half (33-40%) of primiparous women achieved an atraumatic normal vaginal delivery.

Obesity: how much does it matter for female pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS: The objective was to determine the association between body mass index (BMI) and symptoms and signs of female pelvic organ prolapse (POP). METHODS: An observational cross-sectional study of 964 archived datasets of women seen for symptoms and signs of lower urinary tract and pelvic organ dysfunction between September 2011 and February 2014 at a tertiary urogynaecology centre in Australia was carried out. An in-house standardised interview, the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) and 4-D translabial ultrasound, followed by analysis of ultrasound volumes for pelvic organ descent and hiatal area on Valsalva, were performed, blinded against other data. RESULTS: There is a positive association between BMI and posterior compartment prolapse on clinical examination and ultrasound imaging, but not for the anterior and central compartments. There was no association with prolapse symptom bother and a negative association with symptoms of prolapse. CONCLUSIONS: In this observational study, we found a strong association between all tested measures of posterior compartment descent and BMI, both clinical and on imaging.

Can pelvic floor trauma be predicted antenatally?

INTRODUCTION: Levator trauma is a risk factor for the development of pelvic organ prolapse. We aimed to identify antenatal predictors for significant damage to the levator ani muscle during a first vaginal delivery. MATERIAL AND METHODS: A retrospective observational study utilizing data from two studies with identical inclusion criteria and assessment protocols between 2005 and 2014. A total of 1148 primiparae with an uncomplicated singleton pregnancy were recruited and assessed with translabial ultrasound at 36 weeks antepartum and 871 (76%) returned for reassessment 3-6 months postpartum. The ultrasound data of vaginally parous women were analyzed for levator avulsion and microtrauma. The former was diagnosed if the muscle insertion at the inferior pubic ramus in the plane of minimal hiatal dimensions and within 5 mm above were abnormal on tomographic ultrasound imaging. Microtrauma was diagnosed in women with an intact levator and if there was a postpartum increase in hiatal area on Valsalva by >20% with the resultant area ≥25 cm2 . RESULTS: The complete datasets of 844 women were analyzed. Among them, 609 delivered vaginally: by normal vaginal delivery in 452 (54%), a vacuum birth in 102 (12%) and a forceps delivery in 55 (6%). Levator avulsion was diagnosed in 98 and microtrauma in 97. On multivariate analysis, increasing maternal age, lower body mass index and lower bladder neck descent were associated with avulsion. Increased bladder neck descent and a family history of cesarean section (CS) were associcated with microtrauma. CONCLUSIONS: Maternal age, body mass index, bladder neck descent and family history of CS are antenatal predictors for levator trauma.

Predicting levator avulsion from ICS POP-Q findings.

INTRODUCTION AND HYPOTHESIS: Levator avulsion is a common consequence of vaginal childbirth. It is associated with symptomatic female pelvic organ prolapse and is also a predictor of recurrence after surgical correction. Skills and hardware necessary for diagnosis by imaging are, however, not universally available. Diagnosis of avulsion may benefit from an elevated index of suspicion. The aim of this study was to examine the predictive value of the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) for the diagnosis of levator avulsion by tomographic 4D translabial ultrasound. METHODS: This is a retrospective analysis of data obtained in a tertiary urogynaecological unit. Subjects underwent a standardised interview, POP-Q examination and 4D translabial pelvic floor ultrasound. Avulsion of the puborectalis muscle was diagnosed by tomographic ultrasound imaging. We tested components of the ICS POP-Q associated with symptomatic prolapse and other known predictors of avulsion, including previous prolapse repair and forceps delivery with uni- and multivariate logistic regression. A risk score was constructed for clinical use. RESULTS: The ICS POP-Q components Ba, C, gh and pb were all significantly associated with avulsion on multivariate analysis, along with previous prolapse repair and forceps delivery. A score was assigned for each of these variables and patients were classified as low, moderate or high risk according to total score. The odds of finding an avulsion on ultrasound in patients in the "high risk" group were 12.8 times higher than in the "low risk" group. CONCLUSION: Levator avulsion is associated with ICS POP-Q measures. Together with simple clinical data, it is possible to predict the risk of avulsion using a scoring system. This may be useful in clinical practice by modifying the index of suspicion for the condition.

Intrapartum predictors of maternal levator ani injury.

INTRODUCTION: Damage to the pelvic floor during vaginal childbirth is common, and may take the form of levator avulsion or irreversible overdistension of the levator hiatus (microtrauma). Such trauma is a major risk factor for pelvic organ prolapse later in life. In this study we aimed to identify intrapartum risk factors for levator trauma. MATERIAL AND METHODS: This is a retrospective analysis of data obtained in two perinatal studies on primiparous women. Between 2005 and 2014, 1148 women carrying an uncomplicated singleton pregnancy in the late third trimester were seen for 4D pelvic floor ultrasound and an interview. They were invited for a repeat assessment at three months postpartum. RESULTS: Of 1148 women, 871 (76%) returned for assessment at a mean of five months postpartum. The datasets of 844 women were analyzed due to missing data or concurrent pregnancy in 27. In all, 452 (54%) had a normal vaginal delivery, 102 (12%) a vacuum, 55 (6%) a forceps, and 235 (28%) a cesarean section. On multivariate analysis forceps, length of second stage and obstetric anal sphincter tears were significantly associated with levator avulsion. There were no significant predictors identified for irreversible overdistension. CONCLUSIONS: The use of forceps, a prolonged second stage, and obstetric anal sphincter tears were associated with levator avulsion. There were no associated intrapartum predictors for hiatal overdistension.