Re-evaluation of modifiable risk factors for obstetric anal sphincter injury in a real-world setting.

INTRODUCTION AND HYPOTHESIS: The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women. METHODS: This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection. RESULTS: Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height). CONCLUSIONS: Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward.

The Role of Histological Examination of Nail Clipping in the Diagnosis of Onychomycosis.

BACKGROUND: Diagnosis of onychomycosis is based on potassium hydroxide (KOH), direct smear, culture, and polymerase chain reaction. Nail clippings are rarely used as a diagnostic tool. OBJECTIVES: To evaluate nail clippings for the diagnosis of onychomycosis and to compare it to KOH smears. METHODS: Nail clipping specimens of 39 patients were collected: 34 with onychomycosis proved by positive culture and 5 from normal nails. The specimens were submitted to histological processing and then stained with periodic acid-Schiff (PAS) and Grocott-Gomori's methenamine silver (GMS) stains. For each nail, KOH smear was also performed. Two pathologists who had no information on the KOH smear and the culture results evaluated the nail clipping histology for the presence of fungal element. Their assessment was compared to the KOH smear and culture results. RESULTS: Of the 34 specimens that had positive culture, 25 were dermatophytes, 5 were molds, and 4 were candida. Clipping specimens were positive in 30 cases (88%): 23/25 dermatophyte, 4/5 molds, and 3/4 candida. Pathologists were able to classify the pathogens into dermatophytes and non-dermatophytes based on the morphology. PAS stain results were the same as GMS in evaluation of the nail specimen. KOH smear was positive in 29 nails (85%): 20/25 dermatophytes, all 5 molds, and 4 candida. In all five nails where the culture was negative, both clipping and KOH smear did not show fungal elements. CONCLUSIONS: Nail clippings can serve as a rapid, inexpensive, and reliable method for evaluation of onychomycosis, comparable to KOH smear, with the advantage of pathogen group identification.

Toe Web Infection: Epidemiology and Risk Factors in a Large Cohort Study.

INTRODUCTION: Toe web infection (TWI) is a bacterial infection of the interdigital space. In most cases, the infection is caused by gram-negative bacteria, secondary to a chronic fungal infection (dermatophytosis). The typical presentation includes macerations and erosions in the interdigital space. Predisposing factors include interdigital tinea, hyperhidrosis, and humidity. OBJECTIVE: The aim of this study was to characterize the TWI patient population and identify associated risk factors. METHODS: We conducted a retrospective study of patients diagnosed with TWI from 2006 to 2020 at Sheba Medical Center, Israel. Collected data included patients' demographics (age, sex, weight, and occupation), smoking pack-years, comorbidities, medications, and course of disease. RESULTS: A total of 200 patients were diagnosed with TWI. The median age at diagnosis was 51 years. The majority of the patients were men (72.5%). The most common comorbidities were dyslipidemia, hypertension, diabetes, and ischemic heart disease. We found that 71.2% of patients were smokers, and 46.4% of patients had occupations that required closed-toe shoes. TWI incidence did not increase seasonally. Bilateral TWI was found in 50% of the patients, 33% had recurrent infections, and 20% had secondary cellulitis. CONCLUSIONS: Smoking and diabetes were more prevalent among TWI patients than in the general population, and there was a correlation between smoking and TWI recurrences. We identified risk factors for TWI to identify at-risk populations.

The optimal cutoff value for levator-urethra gap measurements using tomographic ultrasound imaging in avulsion diagnosis is population specific.

AIMS: The levator-urethra gap (LUG), the distance between the urethral lumen center and levator insertion on the inferior pubic rami, can be used for diagnosing levator avulsion, with a previously suggested cutoff of LUG ≥2.5 cm. The aim of this study is to determine an optimal cutoff value for LUG measurements in a high-risk patient population. METHODS: Women followed prospectively after sustaining obstetric anal sphincter injury underwent an interview pelvic examination questionnaires and four-dimensional-transperineal ultrasound examination. Levator avulsion was diagnosed on contraction using tomographic ultrasound imaging. Ultrasound datasets were analyzed offline at a later time blinded to previous data. LUG was measured on each side of the three central slices, yielding six measurements and the highest available value was obtained on each side. Different cutoffs were evaluated using receiver-operating characteristics (ROC) curve analysis and Youden's test. The cutoff was validated against symptoms and signs, and sonographic findings using logistic regression analysis. RESULTS: A total of 618 complete datasets were available for analysis, median age 29 years, median body mass index of 23.4 kg/m2 , parity 1, and 26.4% instrumental deliveries. Youden's test and ROC curve analysis gave the best area under the curve of 0.869 for a cutoff of 2.305 (95% confidence interval, 0.839-0.9). Women diagnosed with avulsion based on this cutoff were more symptomatic, whereas using larger cutoffs missed more avulsion defects. CONCLUSION: LUG measurement is useful but should be individualized to the population studied, in our case, in a high-risk population, 2.305 cm was the optimal cutoff. Using larger cutoffs may be more specific but is likely to miss more cases.

Endometriosis and autoimmunity: Can autoantibodies be used as a non-invasive early diagnostic tool?

This review aims to assess the current and past literature for efficacious non-invasive diagnostic markers for earlier detection of endometriosis. We briefly discussed the associations of endometriosis with other autoimmune diseases (AID), as well as the broad changes that occur within the immune system. Specifically, we focused on the usage of various autoantibodies as a potential non-invasive diagnostic tool. Autoantibodies have been noted in the literature since the 1980s and their usage could possibly reduce the delay of an endometriosis diagnosis. Our search concluded that various anti endometrial antibodies may offer useful diagnostic tools. Anti-SLP2, anti-TMOD3, anti-TPM3, and anti-PDIK1L are particularly useful for early diagnosis in minimal to mild endometriosis. Anti-alpha enolase could also be used but yields results similar to CA125. Other non anti endometrial antibodies like anti-IMP1, anti-CA, aCL, anti-STX5 may be used as additional non-invasive diagnostic tools. Anti-TPO may be beneficial in patients in endometriosis patients with concurrent polycystic ovaries syndrome (PCOS). As the pathogenesis of endometriosis continues to reveal itself, more autoantibodies are being discovered and they may offer useful non-invasive tools for the early diagnosis of endometriosis.

Evidence for an association between endometriosis, fibromyalgia, and autoimmune diseases.

PROBLEM: The aim of this study was to investigate the prevalence of and the association between endometriosis, fibromyalgia, and autoimmune disease (AID) in a large population database and to describe healthcare resource utilization (HCRU) in affected women. METHODS: A retrospective cross-sectional study was performed using the computerized databases of Maccabi Healthcare Services (MHS), a 2.1-million-member healthcare plan in Israel. Age-sex-specific point prevalence rates of endometriosis and fibromyalgia were calculated for end of 2015. Socio-demographic characteristics, HCRU, co-morbidities, including AID and depression or anxiety were described according to endometriosis/fibromyalgia status and analyzed using ordinary logistic regression models. RESULTS: Among a total population of 781 571 adult women, 6647 were diagnosed with endometriosis (8.5 per 1000) and 25 425 with fibromyalgia (32 per 1000). A total of 401 women (0.5 per 1000) were diagnosed with both conditions. In 2015, the mean age of the women diagnosed with endometriosis and fibromyalgia was 42 and 55 years, respectively. Women with co-occurrence were characterized by increased HCRU and a high prevalence rate of AID compared to women with no diagnosis of endometriosis/fibromyalgia, with 6.2% diagnosed with inflammatory bowel disease (IBD) vs 1% in the comparison group. The prevalence of fibromyalgia in women with endometriosis was 6%. Adjusted ORs (95% CI) for fibromyalgia among endometriosis patients were 4.1 (2.02-8.36) for systemic lupus erythematosus (SLE), 3.1 (1.5-6.2) for Sjögren syndrome, 2.9 (1.87-4.7) for IBD, 2.1 (1.6-2.7) for dispensed antidepressants, and 1.7 (1.37-2.2) for diagnosed anxiety/depression. CONCLUSION: Co-occurrence of endometriosis and fibromyalgia is associated with a high burden of AID, anxiety/depression, and HCRU.