Operative vaginal delivery and pelvic floor complications.

Operative vaginal delivery (OVD) is associated with injury to the pelvic floor and compromise to the urinary, genital and gastrointestinal systems. There has been significant evolution in recent years in the practice of OVD (from the use of forceps to vacuum delivery), the conduct of delivery (from routine to selective episiotomy) and the recognition and management of obstetric anal sphincter injury (OASIS). This review article considers a number of key questions from the perspective of the clinical practitioner: What effects does OVD have on the pelvic floor? How can the effects of OVD on the pelvic floor be reduced? When and how should episiotomy be performed during OVD? How should future pregnancies following OVD and OASIS be managed? The place of episiotomy during OVD, a much debated strategy to prevent injury to the obstetric anal sphincter during OVD, is considered.

Port insertion for minimally invasive surgery: a report of practices in the Irish Republic.

BACKGROUND: With rapidly evolving surgical technologies, minimally invasive surgery (MIS) has become the mainstay approach for many surgeons worldwide. As laparoscopic surgery was introduced in Ireland over two decades ago, we may be encountering a higher prevalence of related complications. AIMS: This study aimed to gather data pertaining to risk factors for port-site herniation in MIS. METHODS: A 14-point anonymous questionnaire was distributed electronically between January and May 2017 to consultant and trainee laparoscopists in the Republic of Ireland. This survey related to laparoscopic volume and surgical approaches to laparoscopic port-sites. RESULTS: There were 172 eligible responses nationally. Approaches to peritoneal access included Hasson, veress (blind puncture) and SILS were 66.3, 32.6 and 1.2%, respectively. Senior surgeons and specialists in Obstetrics and Gynaecology (OBGYN) reported significantly higher utilisations of closed peritoneal access (p < 0.05). Of the participants, 119 (69.2%) reported using a bladeless trocar over a bladed type. Fascial closure was utilised in 94.2% of ≥ 10 mm and 2.3% of 5-mm ports using absorbable suture in 76.7%, non-absorbable suture in 14.5% and port closure devices in 8.7%. Perceptions of risk factors for PSH were not congruent with significant variations in responses between levels of expertise. CONCLUSIONS: This study demonstrates significant variations in laparoscopic port-site practices amongst surgeons nationally. The new era of practitioners may benefit from evidence-based technical workshops and guidelines to increase awareness and reduce potential complications.

Proposed learning strategies of medical students in a clinical rotation in obstetrics and gynecology: a descriptive study.

BACKGROUND: Medical students face many challenges when learning within clinical environments. How students plan to use their time and engage with learning opportunities is therefore critical, as it may be possible to highlight strategies that optimize the learning experience at an early stage in the rotation. The aim of the study was to describe the learning drivers and proposed learning strategies of medical students for a clinical rotation in obstetrics and gynecology. METHODS: A descriptive study of personal learning plans completed by students at the start of their clinical rotation in obstetrics and gynecology was undertaken. Data relating to students' learning strategies were obtained from the personal learning plans completed by students. Quantitative and qualitative analyses were used. RESULTS: The desire to obtain a good examination result was the most significant reason why the rotation was important to students (n=67/71, 94%). Students struggled to create a specific and practical learning outcome relevant to their career interest. Target scores of students were significantly higher than their reported typical scores (P<0.01). Textbooks were rated as likely to be the most helpful learning resource during the rotation. Bedside tutorials were rated as likely to be the most useful learning activity and small group learning activities were rated as likely to be more useful than lectures. Most students intended to study the course material linked to their clinical program rather than the classroom-based tutorial program. CONCLUSION: The main learning driver for medical students was academic achievement, and the proposed learning strategy favored by medical students was linking their study plans to clinical activities. Medical educators should consider strategies that foster more intrinsic drivers of student learning and more student-oriented learning resources and activities.

Student and staff experiences of attendance monitoring in undergraduate obstetrics and gynecology: a cross-sectional survey.

BACKGROUND: Despite the widespread introduction of active learning strategies to engage students across modern medical curricula, student attendance and attendance monitoring remain a challenging issue for medical educators. In addition, there is little published evidence available to medical educators regarding the use of attendance monitoring systems. The aim of this study was to evaluate the opinions of students and staff about the use of a paper-based student logbook to record student attendance across all clinical and classroom-based learning activities within an undergraduate clinical rotation in obstetrics and gynecology (OBGYN). METHODS: Each student undertaking the clinical rotation in OBGYN was required to complete a paper-based logbook in a booklet format that listed every clinical and classroom-based activity that the student was expected to attend. A cross-sectional survey evaluating the acceptability, practicality, and effect on access to learning opportunities of using the logbook was undertaken. The survey was conducted among all medical students who completed their OBGYN rotation over a full academic year and staff who taught on the program. RESULTS: The response rate was 87% (n=128/147) among students and 80% (n=8/10) among staff. Monitoring attendance was widely acceptable to students (n=107/128, 84%) and staff (n=8/8, 100%). Most students (n=95/128, 74%) and staff (n=7/8, 88%) recommended that attendance should be mandatory during rotations. Almost all staff felt that attendance should contribute toward academic credit (n=7/8, 88%), but students were divided (n=73/128, 57%). Students (n=94/128, 73%) and staff (n=6/8, 75%) reported that the use of the logbook to record attendance with tutor signatures was a satisfactory system, although students questioned the need for recording attendance at every classroom-based activity. Most students felt that the logbook facilitated access to learning experiences during the rotation (n=90/128, 71%). Staff felt that the process of signing logbooks improved their interaction with students (n=6/8, 75%). CONCLUSION: The survey showed that the use of a paper-based logbook to record medical student attendance with tutor signatures across all clinical and classroom-based learning activities was acceptable and practical for students and staff and was felt to facilitate access to learning opportunities. The study provides medical educators with evidence to support monitoring of attendance within clinical rotations.

Team Objective Structured Bedside Assessment (TOSBA) as formative assessment in undergraduate Obstetrics and Gynaecology: a cohort study.

BACKGROUND: Team Objective Structured Bedside Assessment (TOSBA) is a learning approach in which a team of medical students undertake a set of structured clinical tasks with real patients in order to reach a diagnosis and formulate a management plan and receive immediate feedback on their performance from a facilitator. TOSBA was introduced as formative assessment to an 8-week undergraduate teaching programme in Obstetrics and Gynaecology (O&G) in 2013/14. Each student completed 5 TOSBA sessions during the rotation. The aim of the study was to evaluate TOSBA as a teaching method to provide formative assessment for medical students during their clinical rotation. The research questions were: Does TOSBA improve clinical, communication and/or reasoning skills? Does TOSBA provide quality feedback? METHODS: A prospective cohort study was conducted over a full academic year (2013/14). The study used 2 methods to evaluate TOSBA as a teaching method to provide formative assessment: (1) an online survey of TOSBA at the end of the rotation and (2) a comparison of the student performance in TOSBA with their performance in the final summative examination. RESULTS: During the 2013/14 academic year, 157 students completed the O&G programme and the final summative examination . Each student completed the required 5 TOSBA tasks. The response rate to the student survey was 68 % (n = 107/157). Students reported that TOSBA was a beneficial learning experience with a positive impact on clinical, communication and reasoning skills. Students rated the quality of feedback provided by TOSBA as high. Students identified the observation of the performance and feedback of other students within their TOSBA team as key features. High achieving students performed well in both TOSBA and summative assessments. The majority of students who performed poorly in TOSBA subsequently passed the summative assessments (n = 20/21, 95 %). Conversely, the majority of students who failed the summative assessments had satisfactory scores in TOSBA (n = 6/7, 86 %). CONCLUSIONS: TOSBA has a positive impact on the clinical, communication and reasoning skills of medical students through the provision of high-quality feedback. The use of structured pre-defined tasks, the observation of the performance and feedback of other students and the use of real patients are key elements of TOSBA. Avoiding student complacency and providing accurate feedback from TOSBA are on-going challenges.

Impact of a personal learning plan supported by an induction meeting on academic performance in undergraduate Obstetrics and Gynaecology: a cluster randomised controlled trial.

BACKGROUND: A personal learning plan (PLP) is an approach to assist medical students maximise their learning experience within clinical rotations. The aim of this study was to investigate whether medical students who created a PLP supported by an induction meeting had an improved academic performance within an undergraduate clinical rotation. METHODS: A cluster randomised controlled study was conducted over a full academic year (2012/13). The intervention was the creation of a PLP by medical students supported by an individual 'one-to-one' induction meeting between each student and a faculty member. Randomisation was by unit of rotation in which students completed the program. There were 2 clusters in the intervention group (n = 71 students) and 2 clusters in the control group (n = 72 students). Primary outcome was the overall examination score. Secondary outcomes were student attendance and student evaluation. RESULTS: There was no difference in overall examination score between the intervention group and control group (mean score 56.3 ± 4.8% versus 56.7 ± 5.6%, p = 0.64). The majority of students in the intervention group (n = 51/71, 85%) reported that the PLP and induction meeting enhanced their learning experience. Attendance at the induction meeting was identified as a key element. CONCLUSIONS: The creation of a PLP supported by an induction meeting was rated highly by students as an approach to enhance their learning experience but did not result in an improved academic performance. Further research is required to establish the role of an interim or exit meeting.

Student attendance and academic performance in undergraduate obstetrics/gynecology clinical rotations.

IMPORTANCE: Student attendance is thought to be an important factor in the academic performance of medical students, in addition to having important regulatory, policy, and financial implications for medical educators. However, this relationship has not been well evaluated within clinical learning environments. OBJECTIVE: To evaluate the relationship between student attendance and academic performance in a medical student obstetrics/gynecology clinical rotation. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of student attendance at clinical and tutorial-based activities during a full academic year (September 2011 to June 2012) within a publicly funded university teaching hospital in Dublin, Ireland. Students were expected to attend 64 activities (26 clinical activities and 38 tutorial-based activities) but attendance was not mandatory. All 147 fourth-year medical students who completed an 8-week obstetrics/gynecology rotation were included. EXPOSURES: Student attendance at clinical and tutorial-based activities, recorded using a paper-based logbook. MAIN OUTCOMES AND MEASURES: The overall examination score (out of a possible 200 points) was obtained using an 11-station objective structured clinical examination (40 points), an end-of-year written examination comprising 50 multiple-choice questions (40 points) and 6 short-answer questions (40 points), and an end-of-year long-case clinical/oral examination (80 points). Students were required to have an overall score of 100 points (50%) and a minimum of 40 points in the long-case clinical/oral examination (50%) to pass. RESULTS: The mean attendance rate was 89% (range, 39%-100% [SD, 11%], n = 57/64 activities). Male students (84% attendance, P = .001) and students who failed an end-of-year examination previously (84% attendance, P = .04) had significantly lower rates. There was a positive correlation between attendance and overall examination score (r = 0.59 [95% CI, 0.44-0.70]; P < .001). Both clinical attendance (r = 0.50 [95% CI, 0.32-0.64]; P < .001) and tutorial-based attendance (r = 0.57 [95% CI, 0.40-0.70]; P < .001) were positively correlated with overall examination score. The associations persisted after controlling for confounding factors of student sex, age, country of origin, previous failure in an end-of-year examination, and the timing of the rotation during the academic year. Distinction grades (overall score of ≥60%) were present only among students with attendance rates of 80% or higher. The odds of a distinction grade increased with each 10% increase in attendance (adjusted odds ratio, 5.52; 95% CI, 2.17-14.00). The majority of failure grades (6/10 students; 60%) occurred in students with attendance rates lower than 80%. The adjusted odds ratio for failure with attendance rates of 80% or higher was 0.11 (95% CI, 0.02-0.72). CONCLUSIONS AND RELEVANCE: Among fourth-year medical students completing an 8-week obstetrics/gynecology clinical rotation, attendance at clinical and tutorial-based activities was positively correlated with overall examination scores. Further research is needed to understand whether the relationship is causal, and whether improving attendance rates can improve academic performance.

Low levels of copper disrupt brain amyloid-ß homeostasis by altering its production and clearance.

Whereas amyloid-ß (Aß) accumulates in the brain of normal animals dosed with low levels of copper (Cu), the mechanism is not completely known. Cu could contribute to Aß accumulation by altering its clearance and/or its production. Because Cu homeostasis is altered in transgenic mice overexpressing Aß precursor protein (APP), the objective of this study was to elucidate the mechanism of Cu-induced Aß accumulation in brains of normal mice and then to explore Cu's effects in a mouse model of Alzheimer's disease. In aging mice, accumulation of Cu in brain capillaries was associated with its reduction in low-density lipoprotein receptor-related protein 1 (LRP1), an Aß transporter, and higher brain Aß levels. These effects were reproduced by chronic dosing with low levels of Cu via drinking water without changes in Aß synthesis or degradation. In human brain endothelial cells, Cu, at its normal labile levels, caused LRP1-specific down-regulation by inducing its nitrotyrosination and subsequent proteosomal-dependent degradation due in part to Cu/cellular prion protein/LRP1 interaction. In APP(sw/0) mice, Cu not only down-regulated LRP1 in brain capillaries but also increased Aß production and neuroinflammation because Cu accumulated in brain capillaries and, unlike in control mice, in the parenchyma. Thus, we have demonstrated that Cu's effect on brain Aß homeostasis depends on whether it is accumulated in the capillaries or in the parenchyma. These findings should provide unique insights into preventative and/or therapeutic approaches to control neurotoxic Aß levels in the aging brain.

Population-based study of smoking behaviour throughout pregnancy and adverse perinatal outcomes.

There has been limited research addressing whether behavioural change in relation to smoking is maintained throughout pregnancy and the effect on perinatal outcomes. A cohort study addressed lifestyle behaviours of 907 women who booked for antenatal care and delivered in a large urban teaching hospital in 2010-2011. Adverse perinatal outcomes were compared for "non-smokers", "ex-smokers" and "current smokers". Of the 907 women, 270 (30%) reported smoking in the six months prior to pregnancy, and of those 160 (59%) had stopped smoking and 110 (41%) continued to smoke at the time of the first antenatal visit. There was virtually no change in smoking behaviour between the first antenatal visit and the third trimester of pregnancy. Factors associated with continuing to smoke included unplanned pregnancy (OR 1.9; 95% CI 1.3, 2.9), alcohol use (OR 3.4; 95% CI 2.1, 6.0) and previous illicit drug use (OR 3.6; 95% CI 2.1, 6.0). Ex-smokers had similar perinatal outcomes to non-smokers. Current smoking was associated with an average reduction in birth weight of 191 g (95% CI -294, -88) and an increased incidence of intrauterine growth restriction (24% versus 13%, adjusted OR 1.39 (95% CI 1.06, 1.84). Public Health campaigns emphasise the health benefits of quitting smoking in pregnancy. The greatest success appears to be pre-pregnancy and during the first trimester where women are largely self-motivated to quit.

Is RAGE still a therapeutic target for Alzheimer's disease?

The receptor for advanced glycation end products (RAGE) is a multiligand receptor involved in inflammatory disorders, tumor outgrowth, diabetic complications and Alzheimer's disease (AD). RAGE transports circulating amyloid-ß toxins across the blood-brain barrier (BBB) into the brain. RAGE-amyloid-ß toxin interaction at the BBB leads to oxidative stress, inflammatory responses and reduced cerebral blood flow. Thus, regulating RAGE activity at the BBB and/or within brain could be beneficial to AD patients. Herein, the structure-function relation for RAGE-ligand interaction and the role of RAGE as a potential target in the development of treatments for AD and other RAGE-associated disorders are discussed. Despite recent setbacks in the development of RAGE-based therapies for AD, a new generation of compounds that regulate RAGE activity could be efficacious. Careful studies are needed in rodent and nonrodent animal models of AD with new the generation of RAGE antagonists to ensure safety and efficacy in chronic treatment before clinical trials.

A multimodal RAGE-specific inhibitor reduces amyloid ß-mediated brain disorder in a mouse model of Alzheimer disease.

In Alzheimer disease (AD), amyloid ß peptide (Aß) accumulates in plaques in the brain. Receptor for advanced glycation end products (RAGE) mediates Aß-induced perturbations in cerebral vessels, neurons, and microglia in AD. Here, we identified a high-affinity RAGE-specific inhibitor (FPS-ZM1) that blocked Aß binding to the V domain of RAGE and inhibited Aß40- and Aß42-induced cellular stress in RAGE-expressing cells in vitro and in the mouse brain in vivo. FPS-ZM1 was nontoxic to mice and readily crossed the blood-brain barrier (BBB). In aged APPsw/0 mice overexpressing human Aß-precursor protein, a transgenic mouse model of AD with established Aß pathology, FPS-ZM1 inhibited RAGE-mediated influx of circulating Aß40 and Aß42 into the brain. In brain, FPS-ZM1 bound exclusively to RAGE, which inhibited ß-secretase activity and Aß production and suppressed microglia activation and the neuroinflammatory response. Blockade of RAGE actions at the BBB and in the brain reduced Aß40 and Aß42 levels in brain markedly and normalized cognitive performance and cerebral blood flow responses in aged APPsw/0 mice. Our data suggest that FPS-ZM1 is a potent multimodal RAGE blocker that effectively controls progression of Aß-mediated brain disorder and that it may have the potential to be a disease-modifying agent for AD.

Severe maternal morbidity for 2004-2005 in the three Dublin maternity hospitals.

OBJECTIVE: To assess the prevalence and causes of severe maternal morbidity in Dublin over a two year period from 2004 to 2005. STUDY DESIGN: A prospective cohort study from January 2004 to December 2005 was undertaken in the three large maternity hospitals in Dublin, which serve a population of 1.5 million people. All are tertiary referral centres for obstetrics and neonatology and have an annual combined delivery rate of circa 23,000 births. Cases of severe maternal morbidity were identified. A systems based classification was used. The primary cause of maternal morbidity and the number of events experienced per patient was recorded. RESULTS: We identified 158 women who fulfilled the definition for severe maternal morbidity, giving a rate of 3.2 per 1000 maternities. There were two maternal deaths during the time period giving mortality to morbidity ratio of 1:79. The commonest cause of severe morbidity was vascular dysfunction related to obstetric haemorrhage. Eclampsia comprised 15.4% of cases. Intensive care or coronary care admission occurred in 12% of cases. CONCLUSION: The prevalence of severe maternal morbidity in this population is 3.2/1000 maternities. Obstetric haemorrhage was the main cause of severe maternal morbidity.

Radiofrequency ablation of bone with cooled probes and impedance control energy delivery in a pig model: MR imaging features.

PURPOSE: To determine the coronal marrow ablation length and detect cortical thinning after radiofrequency ablation (RFA) of bone in a pig model. MATERIALS AND METHODS: Twelve pigs underwent RFA with a 1- or 2-cm single internally cooled electrode placed at the mid-diaphyseal point of their long bones at 1, 7, or 28 days before euthanasia. Twelve minutes of impedance control radiofrequency energy was delivered at maximum output from a 200-W generator. Pigs were imaged with axial and coronal turbo spin-echo (SE) T1- and T2-weighted frequency-selective fat suppression sequences by using spectral presaturation with inversion recovery (SPIR). A radiologist blinded to the timing of the treatment and the results of other imaging sequences measured the coronal ablation zone length and cortical thickness. The pigs were euthanized, and the ablated bone underwent histologic examination. RESULTS: At SPIR imaging, the zone of marrow ablation was defined as an area of low signal intensity surrounded by a high-signal-intensity band. At T1-weighted imaging, the zone of marrow ablation was defined as a heterogeneously isointense area surrounded by a low-signal-intensity band. The mean (+/-standard deviation) coronal marrow ablation zone measurement with SPIR imaging at 28 days was 47 mm +/- 9 (range, 34-73 mm) for the 1-cm electrode and 51 mm +/- 7 (range, 33-67 mm) for the 2-cm electrode. Two humeral fractures occurred at 21 and 28 days after therapy. Thinning of the cortex adjacent to the electrode insertion site was identified in the humeral group only. CONCLUSION: The change in the marrow signal intensity with impedance-controlled RFA is larger than that reported for temperature-controlled protocols. RFA leads to bone weakening.