The Association Between Depression and Invasive and In-situ Cervical Tumors: A Large Population Based Cohort Study.

BACKGROUND: Depression has been shown to be associated with cervical tumors (CTs), an association mostly demonstrated in studies in which temporality could not have been ascertained. OBJECTIVES: To study the association between depression and CTs and the influence of co-morbidities of this association in a large cohort study. METHODS: A retrospective computer-based cohort study was conducted. The cohort included 357,450 female members of Maccabi Healthcare Services. The cohort was classified as depressed or non-depressed using the International Classification of Diseases 9/10 codes. For each subgroup, demographic characteristics, behavioral characteristics, co-morbidities, and CTs diagnosis were obtained. The burden of co-morbidities was defined as the sum of major co-morbidities. We used zero-inflated negative binomial regression analysis due to over-dispersion to estimate the relative risk (RR) for CTs with 95% confidence interval (95%CI). RESULTS: Depression was diagnosed in 15,789 women. Among this group, CTs were diagnosed in 1585 (10.0%). Among the 341,661 non-depressed, CTs were diagnosed in 4185 (1.2%). After adjustment to age and socioeconomic status, the association between depression and CTs was RR=9.2 (95%CI 8.7-9.9, P-value < 0.0001). The association between depression and CTs increased as the burden of clinical conditions increased (P-value < 0.0001). CONCLUSIONS: Women with depression are at a higher risk for CTs, especially among those who have several co-morbidities. Tighter gynecology surveillance is crucial among these women.

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.

Validation of the Algorithmic Prediction of Failure Modes in Health Care Methodology: Applied to the Department of Sterile Supply and Equipment.

Failure mode and effect analysis (FMEA) is a leading tool for risk management in health care. The term "blanket" approach FMEA describes a comprehensive simultaneous look at the variety of interrelated factors that may directly and indirectly affect patient safety. Applying FMEA with the "blanket" approach is not common, due to FMEA's limitations. Algorithmic prediction of failure modes in health care (APFMH) is leaner and enables the application of the "blanket" approach, but, like FMEA, it lacks formal validation. The authors set out to validate the APFMH method while applying a "blanket" approach. They analyzed the sterile supply handling at a 1900-bed academic medical center. The study's first step took place in the operating room (OR) aspect of the process. An APFMH analysis was performed using the "blanket" approach, to identify the hazards and define the common root causes for predicted hazards. The second step took place a year later at the sterile supply and equipment department (SSED) and aimed to validate these root causes, thus validating the reliability of APFMH. The "blanket" approach analysis with the APFMH method consisted of categorization into 3 risk-dimensions: patient safety, equipment damage, and time management. Root causes were defined for 8 high-ranking hazards. All the root causes for failures, identified by APFMH at the OR department, were revealed as actual hazards in the processes of the SSED. The independent findings at the SSED level validated the list of identified hazards that was formed at the target department (ie, the OR). APFMH methodology is a lean in time and human resources process that ensures comprehensive hazard analysis, which can include the "blanket" approach, and which was validated in this study. The authors suggest using the APFMH methodology for any organizational analysis method that requires the inclusion of "blanket" approaches.

Gender bias in the evaluation of interns in different medical specialties: An archival study.

INTRODUCTION: The field of medicine is characterized by within-field gender segregation: Gender ratios vary systematically by subdisciplines. This segregation might be, in part, due to gender bias in the assessment of women and men medical doctors. METHODS: We examined whether the assessments, i.e. overall score, department scores and skills scores, interns receive by their superiors during their internship year, vary as a function of their gender and the representation of women in the field. We analyzed an archival data set from a large hospital in Israel which included 3326 assessments that were given to all interns who completed their internship year between 2015 and 2019. RESULTS: Women received lower department scores and skills scores in fields with a low (versus high) representation of women. Men received higher scores in fields with a high (versus low) representation of men, yet there was no difference in their skills scores. CONCLUSIONS: Women are evaluated more negatively in fields with a low representation of women doctors. Similarly, men are evaluated more negatively in fields with a low representation of men, yet this cannot be explained by their skills. This pattern of results might point to a gender bias in assessments. A better understanding of these differences is important as assessments affect interns' career choices and options.

Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization.

The goal of our study was to evaluate the burden of endometriosis in the community by comparing healthcare resource utilization, total direct medical costs, infertility, and comorbidity rates of women with and without a diagnosis of endometriosis. A retrospective case-control study was performed using the databases of a 2.1 million-member nationwide healthcare plan. The study population included women aged 15-55 years enrolled in the healthcare plan. Women with a diagnosis (ICD-9) of endometriosis were compared to controls without diagnosed endometriosis. Women were individually matched (1:4) on age and residence area. Patient characteristics were described, including infertility, comorbidities, and annual healthcare resource utilization. Total direct medical costs were analyzed in a generalized linear model adjusting for age. Women with endometriosis (n = 6146, mean age ± SD: 40.4 ± 8.0 y) were significantly more likely than controls (n = 24,572) to have a lower BMI and a higher socioeconomic status. After adjusting for BMI and socioeconomic status, endometriosis was significantly associated with infertility (OR = 3.3; 95% CI 3.1-3.5), chronic comorbidities, higher utilization of healthcare services (hospitalization: OR = 2.3; 95% CI 2.1-2.5), pain medications, and antidepressants. Women aged 15-19 y with endometriosis had substantially higher utilization of primary care visits (57.7% vs. 14.4%) and oral contraceptive use (76.9% vs. 9.6%). Direct medical costs associated with endometriosis were higher than those for controls (OR = 1.75; 95% CI 1.69-1.85). Endometriosis is associated with a high burden of comorbidities, increased healthcare resource utilization, and excess costs, particularly for younger patients whose healthcare needs may differ widely from the older population.

The Association Between Gastrointestinal Symptoms and Transvaginal Ultrasound Findings in Women Referred for Endometriosis Evaluation: A Prospective Pilot Study.

PURPOSE: To evaluate the relationship between gastrointestinal (GI) symptoms and transvaginal ultrasound (TVUS) findings suggestive of endometriosis. MATERIALS AND METHODS: A prospective design. Women referred for a diagnostic ultrasound due to suspicion of endometriosis completed a Rome III and Pelvic Floor Distress Inventory (PFDI-20) questionnaire for clinical, GI symptoms, before undergoing TVUS. Endometriosis was diagnosed in the presence of endometriomas and/or deeply infiltrative endometriotic (DIE) lesions. Association between lesion sites and GI symptoms was evaluated by univariate and multivariate analysis. RESULTS: The study included 241 women who presented with: dysmenorrhea (89.6 %), dyspareunia (76.3 %), chronic pelvic pain (77.2 %), dyschezia (66 %), hematochezia (15.4 %), subfertility (24.5 %). GI symptoms were present in 25.3-76.8 % and 5.4-55.6 % of Rome III and PFDI-20 questionnaire responses, respectively. TVUS findings were endometriomas (23.2 %), peritoneal adhesions (46.5 %), uterosacral ligament (26.7 %), retrocervical (11.2 %), rectosigmoid (11.2 %), intestinal (4.6 %), and bladder (0.8 %) involvement, and pouch of Douglas (POD) obliteration (15.4 %). There was a high prevalence of peritoneal adhesions, uterosacral ligament involvement, and rectosigmoid and intestinal nodules on TVUS in women with GI symptoms, up to Chi2 = 9.639 (p = 0.013) on univariate and Chi2 = 8.102 (p = 0.005) on multivariate analysis. CONCLUSION: We observed an almost 10-fold increase in DIE lesions in women with GI symptoms. We suggest that the presence of GI symptoms should prompt a referral for endometriosis evaluation and performance of a dedicated TVUS before invasive gastrointestinal procedures.

External Validation of the IOTA Classification in Women with Ovarian Masses Suspected to Be Endometrioma.

The study aimed to perform external validation of the International Ovarian Tumor Analysis (IOTA) classification of adnexal masses as benign or malignant in women with suspected endometrioma. A retrospective study including women referred to an endometriosis tertiary referral center for dedicated transvaginal ultrasound (TVUS). Adnexal masses were evaluated using the IOTA classification simple descriptors, simple rules and expert opinion. The reference standard was definitive histology after mass removal at laparoscopy. In total, 621 women were evaluated and divided into four groups: endometrioma on TVUS and confirmed on surgery (Group 1 = 181), endometrioma on TVUS but other benign cysts on surgery (Group 2 = 9), other cysts on TVUS but endometrioma on surgery (Group 3 = 2), masses classified as other findings or suspicious for malignancy on TVUS and confirmed on surgery (Group 4 = 5 potentially malignant, 11 benign). This gave a sensitivity 98.9%, specificity 64%, positive 95.3% and negative 88.9% predictive values, positive 2.74 and negative 0.02 likelihood ratios and 94.7% overall accuracy. The surgical diagnosis for the five masses suspected to be malignant was: borderline serous tumor (2), borderline mucinous tumor (2), and endometrioid lesion with complex hyperplasia without atypia (1). The conclusions were that the IOTA classification simple descriptors, simple rules and expert opinion performs well for classifying adnexal masses suspected to be endometrioma. The most common potentially malignant masses in these women were borderline ovarian tumors.

Re-evaluating Perinatal Group B Streptococcal screening in Israel - Is it time for a change in policy?

Group B streptococcal early-onset disease (EOGBSD) is a significant cause of morbidity and fatality in newborns. Current policy in Israel is risk-based management. Our aim was to re-evaluate the current screening policy for Group B Streptococcus (GBS), considering colonization and prevalence rates and costs estimates. This was a retrospective cohort study including term pregnancies between 2015 and 2016 insured by Maccabi Healthcare Services (MHS). A costs estimation model was performed comparing three approaches: universal culture-based screening, current policy in Israel and the current clinical scenario. Out of 54,759 pregnancies, 46.3% women undergo GBS culture-based screening. Overall GBS colonization rates in screened women were 21%. Six EOGBSD cases were identified, all offspring of mothers who were not screened. EOGBSD prevalence rate was 11 per 100,000. Universal culture-based screening was found to be 50% less costly than the current risk-based policy, and would have prevented 20.29 per 100,000 cases. Universal GBS culture-based screening was found to be more cost-effective, compared to the current policy and screening behaviors. Due to the clinical and economic benefits, we recommend that a change in policy should be considered.

Sonographic Signs of Adenomyosis in Women with Endometriosis Are Associated with Infertility.

We compared the prevalence of ultrasound signs of adenomyosis in women with endometriosis who underwent surgery to those who were managed conservatively. This was a retrospective study of women evaluated at a tertiary endometriosis referral center who underwent 2D/3D transvaginal ultrasound. Adenomyosis diagnosis was based on the presence of at least three sonographic signs. The study group subsequently underwent laparoscopic surgery while the control group continued conservative management. Statistical analysis compared the two groups for demographics, symptoms, clinical data, and sonographic findings. The study and control groups included 244 and 158 women, respectively. The presence of any, 3+, or 5+ sonographic signs of adenomyosis was significantly more prevalent in the study group (OR = 1.93-2.7, p < 0.004, 95% CI; 1.24-4.09). After controlling for age, for all findings but linear striations, the OR for having a specific feature was higher in the study group. Women in the study group with ≥ 5 sonographic signs of adenomyosis had more than twice the risk of experiencing infertility (OR = 2.31, p = 0.012, 95% CI; 1.20-4.45). Sonographic signs of adenomyosis are more prevalent in women with symptomatic endometriosis who underwent surgery compared with those who continued conservative management. Women with 5+ findings have a significantly increased risk of infertility. Adenomyosis on ultrasound should be considered in the management decisions regarding these patients.

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.

The relationship between diastasis rectus abdominus, pelvic floor trauma and function in primiparous women postpartum.

INTRODUCTION AND HYPOTHESIS: A functional interaction exists between the pelvic floor and the abdominal wall. The study was aimed at investigating the clinical and morphological relationships between diastasis rectus abdominus (DRA) and pelvic floor trauma in primiparous women. METHODS: Eighteen women suffering from DRA and 18 women without DRA (non-DRA group), all primiparous with pelvic floor trauma, were enrolled in the study. Ultrasound was performed on the 36 women examining the inter-rectus distance, pelvic floor morphology, abdominal muscle force (MMT), Static Abdominal Flexion Endurance Test (SFET), and Dynamic Abdominal Flexion Endurance Test (DFET), abdominal circumference, visual analog scale, and responses to the Oswestry Low Back Pain Questionnaire and the Pelvic Floor Distress Inventory questionnaire (PFDI). RESULTS: A significant increase in the urinary symptoms portion of the in PFDI-20 questionnaire was found in the DRA group (non-DRA = 12.5 ± 22.8, DRA = 26.8 ± 18.2, p = 0.01). A significant reduction in abdominal force and endurance was observed in the DRA2-3 group compared with the DRA0-1 group (0.025 < p < 0.04). DFET (average repetitions) in the DRA0-1 group measured 13.4 ± 11.8 and 6.46 ± 4.59 in the DRA2-3 group (p = 0.025). SFET was 20.48 ± 14.46 s in the DRA0-1 group and 10.62 ± 10.6 s in the DRA2-3 group (p = 0.031). MMT was 4 in the DRA0-1 group and 3 in the DRA2-3 group (p = 0.04). CONCLUSIONS: Diastasis rectus abdominus does not correlate with morphological changes in the pelvic floor, but does correlate with higher scores in the urinary symptoms portion of the PFDI-20. Women suffering from DRA do not endure more pain or greater lumbar disability than non-DRA women. In extended DRA, the abdominal muscles are significantly compromised and weaker.

Algorithmic prediction of failure modes in healthcare.

BACKGROUND: Preventing medical errors is crucial, especially during crises like the COVID-19 pandemic. Failure Modes and Effects Analysis (FMEA) is the most widely used prospective hazard analysis in healthcare. FMEA relies on brainstorming by multi-disciplinary teams to identify hazards. This approach has two major weaknesses: significant time and human resource investments, and lack of complete and error-free results. OBJECTIVES: To introduce the algorithmic prediction of failure modes in healthcare (APFMH) and to examine whether APFMH is leaner in resource allocation in comparison to the traditional FMEA and whether it ensures the complete identification of hazards. METHODS: The patient identification during imaging process at the emergency department of Sheba Medical Center was analyzed by FMEA and APFMH, independently and separately. We compared between the hazards predicted by APFMH method and the hazards predicted by FMEA method; the total participants' working hours invested in each process and the adverse events, categorized as 'patient identification', before and after the recommendations resulted from the above processes were implemented. RESULTS: APFMH is more effective in identifying hazards (P < 0.0001) and is leaner in resources than the traditional FMEA: the former used 21 h whereas the latter required 63 h. Following the implementation of the recommendations, the adverse events decreased by 44% annually (P = 0.0026). Most adverse events were preventable, had all recommendations been fully implemented. CONCLUSION: In light of our initial and limited-size study, APFMH is more effective in identifying hazards (P < 0.0001) and is leaner in resources than the traditional FMEA. APFMH is suggested as an alternative to FMEA since it is leaner in time and human resources, ensures more complete hazard identification and is especially valuable during crisis time, when new protocols are often adopted, such as in the current days of the COVID-19 pandemic.

Validation of Lung EpiCheck, a novel methylation-based blood assay, for the detection of lung cancer in European and Chinese high-risk individuals.

AIM: Lung cancer screening reduces mortality. We aim to validate the performance of Lung EpiCheck, a six-marker panel methylation-based plasma test, in the detection of lung cancer in European and Chinese samples. METHODS: A case-control European training set (n=102 lung cancer cases, n=265 controls) was used to define the panel and algorithm. Two cut-offs were selected, low cut-off (LCO) for high sensitivity and high cut-off (HCO) for high specificity. The performance was validated in case-control European and Chinese validation sets (cases/controls 179/137 and 30/15, respectively). RESULTS: The European and Chinese validation sets achieved AUCs of 0.882 and 0.899, respectively. The sensitivities/specificities with LCO were 87.2%/64.2% and 76.7%/93.3%, and with HCO they were 74.3%/90.5% and 56.7%/100.0%, respectively. Stage I nonsmall cell lung cancer (NSCLC) sensitivity in European and Chinese samples with LCO was 78.4% and 70.0% and with HCO was 62.2% and 30.0%, respectively. Small cell lung cancer (SCLC) was represented only in the European set and sensitivities with LCO and HCO were 100.0% and 93.3%, respectively. In multivariable analyses of the European validation set, the assay's ability to predict lung cancer was independent of established risk factors (age, smoking, COPD), and overall AUC was 0.942. CONCLUSIONS: Lung EpiCheck demonstrated strong performance in lung cancer prediction in case-control European and Chinese samples, detecting high proportions of early-stage NSCLC and SCLC and significantly improving predictive accuracy when added to established risk factors. Prospective studies are required to confirm these findings. Utilising such a simple and inexpensive blood test has the potential to improve compliance and broaden access to screening for 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.

Ultrasonography in Pelvic Floor Dysfunction.

Obstetric anal sphincter injury (OASI) and levator ani muscle (LAM) trauma are common disorders in parous women. Four sonographic signs have been published in cases of OASI: external or internal anal sphincter discontinuity; thickening of external anal sphincter at the area of repair; thinning of internal anal sphincter in the area of rupture in conjunction with thickening opposite the rupture site ("half-moon" sign); and abnormality of mucous folds ("mucosal star sign"). Levator trauma can be asymptomatic, with abnormality arising years later. Discontinuity of the LAM is the main sonographic sign but may appear as increased hiatal area in severe cases.

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.

Ultrasound visualization of sacrocolpopexy polyvinylidene fluoride meshes containing paramagnetic Fe particles compared with polypropylene mesh.

INTRODUCTION AND HYPOTHESIS: Paramagnetic Fe particles can be added during synthetic mesh production to allow visibility on magnetic resonance imaging. Our aim was to evaluate whether transperineal ultrasound (TPUS) allows visualization, measurement, and characterization of polyvinylidene fluoride (PVDF mesh) containing Fe particles compared with regular polypropylene (PP) meshes used for sacrocolpopexy. METHODS: Women up to 1.5 years after laparoscopic sacrocolpopexy who were implanted with a PP or PVDF mesh underwent clinical examination and 2D, 3D, and 4D TPUS. Acquired volumes were analyzed offline for mesh position at rest and maximal Valsalva and for mesh dimensions and characteristics, with the operator blinded to group assignment. The two groups were compared. RESULTS: There were 17 women in the PP and 25 in the PVDF mesh group, without differences in baseline demographics. None had significant prolapse, recurrence, symptoms, or complications. On TPUS, mesh was visible in all patients both caudally (perineal) and cranially but was more echogenic in the PVDF mesh group. Mesh length from distal to proximal that was visible on TPUS was longer for PVDF mesh, for both anterior and posterior vaginal arms (all P < 0.05), and for mesh above the vaginal apex (P = 0.002). The inferior aspects of the mesh showed areas of double mesh layers, suggesting folding in 80% of women in both groups, without symptoms. CONCLUSIONS: PVDF mesh permits clearer visualization and is seen over a longer stretch on TPUS, with longer visible mesh arms. The latter can be due to differences in operative technique, presence of microparticles, implant textile structure, or patient characteristics.

Infertility treatments during pregnancy and the risk of autism spectrum disorder in the offspring.

We aimed to examine the effects of infertility treatments on the risk of Autism Spectrum Disorder (ASD). Data were from a representative national registry on 110,093 male live births in Israel (born: 1999-2008; and ASD: 975, 0.9%). Infertility treatments included In Vitro Fertilization (IVF), and five hormone treatments. Relative risk (RR) was estimated with multivariable logistic models. Results showed that IVF treatment compared with spontaneous conception was not statistically significantly associated with the risk of ASD. Only progesterone hormone treatment was associated with a statistically significant (p < .05) increased risk of ASD (RR = 1.51, 95% CI 1.22, 1.86) compared to the group with no progesterone treatment. In conclusion, progesterone exposure during the critical period of fetal life elevated the risk of ASD, possibly reflecting epigenetic modification.

Environmental exposures and fetal growth: the Haifa pregnancy cohort study.

BACKGROUND: The developing fetus is susceptible to environmental insults. Studying the effects of environmental exposures on fetal growth is essential for understanding the causal pathway between prenatal exposures and pregnancy outcomes. Here we describe the Haifa Pregnancy Cohort Study (HPCS) and discuss challenges and opportunities in applying "big data" paradigm. METHODS: Maccabi Healthcare Services (MHS), is the second largest Israeli health maintenance organization (HMO) providing care services to two million beneficiaries. The HPCS cohort potentially includes ~750,000 newborns born between 1998 and 2017. We will estimate daily exposures to air pollutants, temperature and greenness, using satellite-based data and models. We hypothesize that residents of Haifa have higher exposures to environmental pollutants and that in pregnant women this higher exposure is associated with poorer fetal growth. We will evaluate outcomes such as birth-weight, head-circumference and gestational age at birth. We will adjust for pregnancy complications such as pre-eclampsia and gestational diabetes and parental variables, such as maternal weight, age and smoking habits as potential confounders. In addition, we will conduct a multi-tiered field study, nested within this population, among 150 pregnant women residing in two geographical regions-one in the polluted Haifa area, and one in a relatively unpolluted area in central Israel. Blood and urinary samples will be collected, as well as personal and indoor exposure to air pollution. DISCUSSION: Evaluating environmental exposures of pregnant women and assessing in utero growth over the course of the pregnancy during different exposure windows, is of great scientific and public health interest. Recent advances in data collection and analysis pose great promise to provide insights into contribution of environment to the health of the developing fetus, but also pose major challenges and pitfalls, such as data management, proper statistical framework and integration of data in the population-based study and selectiveness in the nested field study. Yet the continuing follow-up of the study cohort, integrating data from different services, health-promotion, and eventually, application later in real life of our main promises. Our study aims to meet these challenges and to provide evidence of the environmental exposures associated with fetal growth.

Sonographic Signs of Adenomyosis Are Prevalent in Women Undergoing Surgery for Endometriosis and May Suggest a Higher Risk of Infertility.

OBJECTIVES: To determine the prevalence of ultrasound features suggestive of adenomyosis in women undergoing surgery for endometriosis compared with a control group of healthy women without endometriosis. METHODS: Retrospective case-control study comparing women with intractable pain or infertility, who underwent transvaginal ultrasound and subsequent laparoscopic surgery, with a control group of healthy women without a previous history of endometriosis. A diagnosis of adenomyosis on TVUS was made based on asymmetrical myometrial thickening, linear striations, myometrial cysts, hyperechoic islands, irregular endometrial-myometrial junction, parallel shadowing, and localized adenomyomas and analyzed for one sign and for three or more signs. RESULTS: The study and control groups included 94 and 60 women, respectively. In the study group, women were younger and had more dysmenorrhea and infertility symptoms. The presence of any sonographic feature of adenomyosis, as well as three or more signs, was found to be more prevalent in the study group, which persisted after controlling for age, for all features but linear striations. Women in the study group who had five or more sonographic features of adenomyosis had more than a threefold risk of suffering from infertility (OR = 3.19, p = 0.015, 95% CI; 1.25-8.17). There was no association with disease severity at surgery. CONCLUSIONS: Sonographic features of adenomyosis are more prevalent in women undergoing surgery for endometriosis compared to healthy controls. Women with more than five features had an increased risk of infertility.