Rotational forceps versus manual rotation and direct forceps: A retrospective cohort study.

OBJECTIVE: Rotational forceps and manual rotation followed by direct forceps are techniques used in the management of malposition of the fetal head in the second stage of labor. However, there is widespread debate regarding their relative safety and utility. We aimed to compare the effectiveness and safety of rotational forceps with manual rotation followed by direct forceps, for management of fetal malposition at full dilation. STUDY DESIGN: A retrospective cohort study in a single tertiary obstetric unit with >6000 births per year. We recorded and analysed outcomes of 104 sequential rotational forceps births over 21 months (Jan 2010-Sept 2012) and 208 matched chronologically sequential attempted manual rotations and direct forceps births (1:2 by number). Univariable and multivariable approaches used for statistical analysis. The main outcome measure was vaginal birth. RESULTS: The rate of vaginal birth was significantly higher with rotational forceps than with manual rotation followed by direct forceps (88.5% vs 82.2%, RR 1.17, 95% CI 1.04-1.31, p=0.017). Births by rotational forceps were associated with a significantly higher rate of shoulder dystocia (19.2% vs 10.6%, RR 2.35, 95% CI 1.23-4.47, p=0.012), but not of neonatal injury. There were no significant differences in all other maternal and neonatal outcomes between the two modes of birth. CONCLUSIONS: The use of rotational forceps was associated with a statistically significantly higher rate of vaginal birth, but also of shoulder dystocia, compared to manual rotation followed by direct forceps. This is the first study to demonstrate a statistically significant increase in the rate of shoulder dystocia following rotational forceps birth.

Hybrid simulation compared to manikin alone in teaching pelvic examinations: a randomised control trial.

Introduction: Performing a pelvic examination is a core skill for all medical undergraduates. The use of hybrid simulation, manikin with patient actress, to attain technical and communication skills competencies and to improve the quality of care we offer women, has not been compared to other teaching methods before. Outcome measures were technical skills, communication skills and confidence in completing a pelvic examination. Methods: A cluster randomised control trial was conducted over an academic year. Forty-eight medical students who completed an 8-week obstetrics and gynaecology attachment were recruited. Clusters were randomly assigned for initial training on hybrid or manikin only models and attended an end of attachment Objective Structured Clinical Assessment. Results: Outcome data were received for 43/48 students (89.5%). Following the objectively structured clinical examination, the hybrid trained cohort had higher technical scores (mean 23 (95% CI 20.1 to 25.8) vs 16.7 (CI 14.7 to 18.6); mean difference 6.3, CI 3.0 to 9.6) and communication skills scores (mean 22.6 (CI 21.2 to 23.8) vs 15.9 (CI 14.4 to 17.3); mean difference 6.7, CI 4.8 to 8.5) compared to the manikin only trained participants. Confidence in undertaking future pelvic examinations were similar in the control and intervention groups; (p=0.10, r=0.18). Conclusions: This study demonstrates the value of hybrid simulation compared to manikins alone in improving the short-term acquisition of competence in simulated pelvic examinations at an undergraduate level. Future research should focus on whether hybrid models lead to long-term acquisition of skill and comparison of these models with other innovative methods such as clinical teaching associates.

Using singing to nurture children's hearing? A pilot study.

This article reports a pilot study of the potential benefits of a sustained programme of singing activities on the musical behaviours and hearing acuity of young children with hearing impairment (HI). Twenty-nine children (n=12 HI and n=17 NH) aged between 5 and 7 years from an inner-city primary school in London participated, following appropriate ethical approval. The predominantly classroom-based programme was designed by colleagues from the UCL Institute of Education and UCL Ear Institute in collaboration with a multi-arts charity Creative Futures and delivered by an experienced early years music specialist weekly across two school terms. There was a particular emphasis on building a repertoire of simple songs with actions and allied vocal exploration. Musical learning was also supported by activities that drew on visual imagery for sound and that included simple notation and physical gesture. An overall impact assessment of the pilot programme embraced pre- and post-intervention measures of pitch discrimination, speech perception in noise and singing competency. Subsequent statistical data analyses suggest that the programme had a positive impact on participant children's singing range, particularly (but not only) for HI children with hearing aids, and also in their singing skills. HI children's pitch perception also improved measurably over time. Findings imply that all children, including those with HI, can benefit from regular and sustained access to age-appropriate musical activities.

Modified obstetric early warning scoring systems (MOEWS): validating the diagnostic performance for severe sepsis in women with chorioamnionitis.

OBJECTIVE: We sought to compare the predictive power of published modified obstetric early warning scoring systems (MOEWS) for the development of severe sepsis in women with chorioamnionitis. STUDY DESIGN: This was a retrospective cohort study using prospectively collected clinical observations at a single tertiary unit (Chicago, IL). Hospital databases and patient records were searched to identify and verify cases with clinically diagnosed chorioamnionitis during the study period (June 2006 through November 2007). Vital sign data (heart rate, respiratory rate, blood pressure, temperature, mental state) for these cases were extracted from an electronic database and the single worst composite recording was identified for analysis. Global literature databases were searched (2014) to identify examples of MOEWS. Scores for each identified MOEWS were derived from each set of vital sign recordings during the presentation with chorioamnionitis. The performance of these MOEWS (the primary outcome) was then analyzed and compared using their sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic curve for severe sepsis. RESULTS: Six MOEWS were identified. There was wide variation in design and pathophysiological thresholds used for clinical alerts. In all, 913 women with chorioamnionitis were identified from the clinical database. In all, 364 cases with complete data for all physiological indicators were included in analysis. Five women developed severe sepsis, including 1 woman who died. The sensitivities of the MOEWS in predicting the severe deterioration ranged from 40-100% and the specificities varied even more ranging from 4-97%. The positive predictive values were low for all MOEWS ranging from <2-15%. The MOEWS with simpler designs tended to be more sensitive, whereas the more complex MOEWS were more specific, but failed to identify some of the women who developed severe sepsis. CONCLUSION: Currently used MOEWS vary widely in terms of alert thresholds, format, and accuracy. Most MOEWS have not been validated. The MOEWS generally performed poorly in predicting severe sepsis in obstetric patients; in general severe sepsis was overdetected. Simple MOEWS with high sensitivity followed with more specific secondary testing is likely to be the best way forward. Further research is required to develop early warning systems for use in this setting.

Realism and construct validity of novel pelvic models of common gynecologic conditions.

OBJECTIVE: To test a novel set of pelvic trainers for realism and construct validity. METHODS: Seven models of the female pelvis were studied. Participants performed speculum and bimanual examinations, documented their findings, and recorded opinions of the models in a structured questionnaire. Results were analyzed by participant grade (inexperienced and experienced). RESULTS: Twenty-six inexperienced and 24 experienced gynecologists participated. Experienced doctors were more likely to correctly identify the uterus corresponding to 16 weeks of gestation (P<0.001), the large fibroid uterus (P=0.01), and uterine anteversion (P=0.04). Identification of the uterus containing a small fibroid, the uterus corresponding to 10 weeks of gestation, and an adnexal cyst was low overall (<35%) and not significantly different between the groups. Correct identification of cervical findings (ectropion and polyp) was high in both groups (65%-88%). Experienced doctors were more consistent-with 17 (71%) reporting the same correct finding on a repeated model, compared with 8 (31%) inexperienced doctors. Forty-nine (98%) doctors completed the structured questionnaire, 36 (73%) of whom felt the models were realistic. CONCLUSION: The models were found to be realistic and have construct validity. Senior participants were consistent at correctly identifying most abnormalities. The models may be useful for pelvic examination training; further testing is required regarding their ability to aid learning of clinical and communication skills.

Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies.

Poor teamwork results in preventable morbidity and mortality for mothers and babies. Suboptimal communication and lack of leadership cost not only lives but also money that is diverted from clinical care to insurance and litigation. Avoidable harm is usually not the result of staff failing their duty of care, it is the result of poor training failing hard-worked staff. A few simple teamwork and leadership behaviours can make a huge difference to outcome and experience for women and their companions, yet they are often missing from maternity care. Recent research has identified the problems and solutions, including the best way to train maternity teams to make a palpable difference. We describe simple yet evidence-based methods to improve teams and leaders.

Brown-Vialetto-Van Laere syndrome, a ponto-bulbar palsy with deafness, is caused by mutations in c20orf54.

Brown-Vialetto-Van Laere syndrome is a rare neurological disorder with a variable age at onset and clinical course. The key features are progressive ponto-bulbar palsy and bilateral sensorineural deafness. A complex neurological phenotype with a mixed picture of upper and lower motor neuron involvement reminiscent of amyotrophic lateral sclerosis evolves with disease progression. We identified a candidate gene, C20orf54, by studying a consanguineous family with multiple affected individuals and subsequently demonstrated that mutations in this gene were the cause of disease in other, unrelated families.

Voriconazole therapy in children with cystic fibrosis.

BACKGROUND: There is increasing evidence for the efficacy of the antifungal voriconazole, particularly in immunosuppression. We describe our experience of using voriconazole in children with CF. METHODS: We performed a retrospective case note review of children with CF treated with voriconazole in a single centre over an 18 month period. RESULTS: A total of 21 children aged 5 to 16 years (median 11.3) received voriconazole for between 1 and 50 (22) weeks. Voriconazole was used as monotherapy in 2 children with recurrent allergic bronchopulmonary aspergillosis (ABPA); significant and sustained improvements in clinical and serological parameters for up to 13 months were observed, without recourse to oral steroids. Voriconazole was used in combination with an immunomodulatory agent in a further 11 children with ABPA, with significant improvement in pulmonary function and serology. 8 children without ABPA but who had recurrent Aspergillus fumigatus isolates and increased symptoms also received voriconazole; this group did not improve with treatment. Adverse effects occurred in 7 children (33%: photosensitivity reaction 3, nausea 2, rise in hepatic enzymes 1, hair loss 1). CONCLUSIONS: Voriconazole may be a useful adjunctive therapy for ABPA in CF. Voriconazole monotherapy appears to be an alternative treatment strategy when oral corticosteroids may not be suitable.

Transgenes encompassing dual-promoter CpG islands from the human TBP and HNRPA2B1 loci are resistant to heterochromatin-mediated silencing.

The genetic elements that are responsible for establishing a transcriptionally competent, open chromatin structure at a region of the genome that consists only of ubiquitously expressed, housekeeping genes are currently unknown. We demonstrate for the first time through functional analysis in stably transfected tissue culture cells that transgenes containing methylation-free CpG islands spanning the dual divergently transcribed promoters from the human TATA binding protein (TBP)-proteasome component-B1 (PSMB1) and heterogeneous nuclear ribonucleoprotein A2/B1 (HNRPA2B1)-heterochromatin protein 1Hs-gamma (chromobox homolog 3, CBX3) gene loci are sufficient to prevent transcriptional silencing and a variegated expression pattern when integrated within centromeric heterochromatin. In addition, only transgene constructs extending over both the HNRPA2B1 and the CBX3 promoters, and not the HNRPA2B1 promoter alone, were able to confer high and stable long-term EGFP reporter gene expression. These observations suggest that methylation-free CpG islands associated with dual, divergently transcribed promoters possess an independent dominant chromatin opening function and may therefore be major determinants in establishing and maintaining a region of open chromatin at housekeeping gene loci.

Redox poise and oxygenation of cytochrome bd in the diazotroph Azotobacter vinelandii assessed in vivo using diode-array reflectance spectrophotometry.

A ferrous oxygenated form of cytochrome d is characteristic of all cytochrome bd-type oxidases so far examined, but its participation in enzyme turnover is unclear. It is relatively stable, occurs in aerated cell suspensions and predominates during enzyme preparation. In this study, diode-array reflectance spectrophotometry was used to assess the redox poise and oxygenation of cytochrome bd in vivo, in the aerobic diazotroph Azotobacter vinelandii. Mutants either lacking or overproducing the cytochrome bd oxidase were used to confirm the reliability of the optical configuration. Changes in absorbance attributed to cytochromes b, c and d were followed as the O2 supply was altered either in suspensions of harvested cells or during steady-state growth. In washed cell suspensions, three states of cytochrome d, which differed in absorbance characteristics, were seen: (1) an oxygenated form that absorbs at 650 nm, (2) a form which has little absorbance at either 650 or 630 nm and (3) the reduced form that absorbs at 630 nm. The transition between states 2 and 3, but not 1 and 2, correlated with the changes in the redox states of cytochromes b595 and b560. The dissolved O2 concentration at which this transition occurred coincided approximately with the apparent O2 affinity for the oxidase in vivo (approx. 5 microM). During steady-state growth, the cytochromes were partially reduced and the oxygenated form of cytochrome d was undetected. These in situ measurements support the view that an oxygenated form of cytochrome d (absorbing at 650 nm) in the one-electron-reduced cytochrome bd-type oxidase does not take part in enzyme turnover.