The effectiveness of immediate versus delayed tubal flushing with oil-based contrast in women with unexplained infertility (H2Oil-timing study): study protocol of a randomized controlled trial.

BACKGROUND: In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography leads to significantly more live births as compared to tubal flushing with water-based contrast during hysterosalpingography. However, it is unknown whether incorporating tubal flushing with oil-based contrast in the initial fertility work-up results to a reduced time to conception leading to live birth when compared to delayed tubal flushing that is performed six months after the initial fertility work-up. We also aim to evaluate the effectiveness of tubal flushing with oil-based contrast during hysterosalpingography versus no tubal flushing in the first six months of the study. METHODS: This study will be an investigator-initiated, open-label, international, multicenter, randomized controlled trial with a planned economic analysis alongside the study. Infertile women between 18 and 39 years of age, who have an ovulatory cycle, who are at low risk for tubal pathology and have been advised expectant management for at least six months (based on the Hunault prediction score) will be included in this study. Eligible women will be randomly allocated (1:1) to immediate tubal flushing (intervention) versus delayed tubal flushing (control group) by using web-based block randomization stratified per study center. The primary outcome is time to conception leading to live birth with conception within twelve months after randomization. We assess the cumulative conception rate at six and twelve months as two co-primary outcomes. Secondary outcomes include ongoing pregnancy rate, live birth rate, miscarriage rate, ectopic pregnancy rate, number of complications, procedural pain score and cost-effectiveness. To demonstrate or refute a shorter time to pregnancy of three months with a power of 90%, a sample size of 554 women is calculated. DISCUSSION: The H2Oil-timing study will provide insight into whether tubal flushing with oil-based contrast during hysterosalpingography should be incorporated in the initial fertility work-up in women with unexplained infertility as a therapeutic procedure. If this multicenter RCT shows that tubal flushing with oil-based contrast incorporated in the initial fertility work-up reduces time to conception and is a cost-effective strategy, the results may lead to adjustments of (inter)national guidelines and change clinical practice. TRIAL REGISTRATION NUMBER: The study was retrospectively registered in International Clinical Trials Registry Platform (Main ID: EUCTR2018-004153-24-NL).

Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study).

BACKGROUND: In women with unexplained infertility, tubal flushing with oil-based contrast during hysterosalpingography (HSG) increases ongoing pregnancy and subsequent live birth rates when compared to tubal flushing with water-based contrast. It is currently unclear whether an HSG with oil-based contrast also results in more ongoing pregnancies and live births in women of advanced age, women with ovulation disorders, and women with potential tubal pathology when compared to an HSG with water-based contrast. METHODS: We plan an international, multicentre, open-label, randomized controlled trial (RCT) studying three groups of infertile women who have an indication for tubal patency testing according to their treating physician and additionally; (1) are 39 years of age or older, (2) have an ovulation disorder or (3) have a high risk for tubal pathology based on their medical history. Women with an allergy for iodinated contrast medium are excluded, as are women with diabetes, hyperprolactinemia or untreated hyper- or hypothyroidism, and women with a partner with severe male infertility. After informed consent, women will be randomly allocated to the intervention, tubal flushing with the use of oil-based contrast during HSG or the control group, tubal flushing with the use of water-based contrast during HSG in a 1:1 ratio by the web-based system Castor. The primary endpoint will be ongoing pregnancy leading to live birth with conception within six months after randomization. Secondary outcomes are other pregnancy outcomes, used fertility treatments, adverse events and cost-effectiveness. Based on the expected ongoing pregnancy rate of 17% in the control group and 27% in the intervention group, the sample size will be 930 women (465 per group). Study inclusion is expected to be complete in four years. DISCUSSION: This multicentre RCT will establish whether, for women of advanced age, women with ovulatory disease, and women who have a high risk for tubal pathology, there is a fertility enhancing effect of tubal flushing with oil-based contrast during HSG and whether the use of this contrast medium is cost-effective. Trial Registration The study was prospectively registered in the Netherlands Trial Register on August 1st 2019 as 'H2Oil2' (reference number NL7925, https://www.trialregister.nl/trial/7925 ).

Can humanization theory contribute to the philosophical debate in public health?

This paper will explore the humanization value framework for research, policy and practice with regard to its relevance for public health, specifically the reduction of inequities in health. This proposed framework introduces humanizing values to influence research, policy and practice. The framework is articulated through eight specific constituents of what it is to be human. These dimensions are articulated as humanizing and dehumanizing dimensions that have the potential to guide both research and practice. The paper will then go on to consider these dimensions in relation to the emergent qualities of the potential 'fifth-wave' of public health intervention. The humanization dimensions outlined in this paper were presented as emerging from Husserl's notion of lifeworld, Heidegger's contemplations about human freedom and being with others, and Merleau-Ponty`s ideas about body subject and body object. Husserl's ideas about the dimensions that make up 'lifeworld', such as embodiment, temporality and spatiality, underpin the suggested dimensions of what it is to be human. They are proposed in the paper as together informing a value base for considering the potentially humanizing and dehumanizing elements in systems and interactions. It is then proposed that such a framework is useful when considering methods in public health, particularly in relation to developing new knowledge of what is both humanizing and dehumanizing within research and practice.

Surfing the net for public health resources.

OBJECTIVES: To identify public health open educational resources (OER) available online, map the identified OER to The Public Health Skills and Career Framework (PHSCF), and triangulate these findings with public health practitioners. STUDY DESIGN: Systematic online search for public health OER. METHODS: An online search was undertaken using a pre-defined set of search terms and inclusion/exclusion criteria. Public health OER were then mapped against the UK PHSCF. The findings of the search were discussed with public health specialists to determine whether or not they used these resources. RESULTS: A number of public health OER were identified, located on 42 websites from around the world. Mapping against the UK PHSCF demonstrated a lack of coverage in some areas of public health education. It was noted that many of the OER websites identified were not those generally used in practice, and those sites preferred by public health specialists were not identified by the online search. CONCLUSIONS: Public health OER are available from a number of providers, frequently universities and government organizations. However, these reflect a relatively small pool of original OER providers. Tagging of websites does not always identify their public health content. In addition, users of public health OER may not use search engines to identify resources but locate them using other means.

An emerging model for publishing and using open educational resources in public health.

INTRODUCTION: The open source revolution has enabled the development of open educational resources (OER) and the potential for sharing lessons learned. We present a potential model for publishing OER in public health to inform workforce development. METHODS: As part of the PHORUS (Public Health Open Resources for the University Sector) Project, a review of the literature relating to the development of OER was followed by an online search for OER resources relating specifically to public health. Furthermore, a Delphi study was conducted to identify and prioritize barriers and enablers to the production and use of public health OER. RESULTS: A wide array of OER literature was identified, although there were a limited number of public health-related papers. The key concepts influencing public health OER release found in the literature were identified as quality, ethics and values, rewards, risks and practical aspects, such as technological developments. These concepts were then further developed through the PHORUS project research findings to produce the basis of a potential model for OER development in public health. DISCUSSION/CONCLUSION: The synthesis of a literature review and Delphi study has produced a potential model to guide the development of OER in public health. The model provides a matrix where the questions about whether and how an academic can produce and publish OER are answered, according to various risks and benefits to them and their institution. We hope that this will provide practical assistance and encouragement for the academic public health community to create and share OER.

Hysterosalpingogram: an essential examination following Essure hysteroscopic sterilisation.

OBJECTIVES: The aim of this study was to describe our experience of imaging following hysteroscopic sterilisation with the Essure (Conceptus Inc., Mountain View, San Carlos, CA) microinsert, and to underline the importance of a carefully performed follow-up hysterosalpingogram (HSG) in the management of these patients. METHODS: 18 women underwent the procedure and all returned for follow-up HSG. A standard HSG technique was used and views were acquired to establish microinsert position and tubal occlusion. RESULTS: In 16 of the 18 women, adequate microinsert positioning and bilateral tubal occlusion was present. In one woman, a unilateral microinsert occluded the fallopian tube, whereas the other fallopian tube was ligated with a clip. The final patient underwent two studies; both showed well-positioned microinserts but unilateral free spill from the right fallopian tube. There are no reported pregnancies thus far. CONCLUSION: Essure sterilisation coils have a unique appearance when radiographed and are an effective means of permanently occluding the fallopian tubes. HSG is a rapid and safe method of confirming satisfactory placement and tubal occlusion. Non-HSG imaging techniques are suboptimal at detecting patent fallopian tubes and expose patients to the risk of an unwanted and potentially complicated pregnancy.

Enabling nursing students to focus on the Ottawa Charter and the nurses role in tackling inequalities in health through international exchange.

Student nurses in a transatlantic exchange program explored the role of registered nurses in five countries' public health systems. The Ottawa Charter provided a framework for students to examine the nurse's responsibilities in public health. Students took practice placements in geographically rural a reason another continent and explored inequalities in health care. If nurses are to understand their role in the health care system then they must be taught the scope of their practice including their role in health promotion,public health practice and community development. For this project nursing instructors developed an assignment relevant to the aims and suitable for students in all five nursing programs. Only three of 48 students offered an assignment which focused on building healthy public policy. Nurse educators need to explore this further to ensure nurses of the future are aware of their role and responsibilities in this area and have skills to work effectively to influence and build healthy policy. The international student exchange supported the students' developing understanding of the breadth of initiatives around the globe where nurses are actively engaged in addressing inequalities of health. Findings from an analysis of their assignments are presented in this evaluative report.

Sustainable Urban Drainage Systems (SUDS) treatment train assessment tool.

This paper outlines a rationale and scoring system for the stormwater treatment train assessment tool (STTAT) which is a proposed regulatory tool for Sustainable Urban Drainage Systems (SUDS). STTAT provides guidance and regulatory consistency for developers about the requirements of planners and the Scottish Environment Protection Agency (SEPA). The tool balances the risks of pollution to the receiving water body with the treatment provided in a treatment train. It encourages developers to take SUDS into account early, avoiding any misunderstanding of SUDS requirements at the planning stage of a development. A pessimistic view on pollution risks has been adopted since there may be a change of land use on the development in the future. A realistic view has also been taken of maintenance issues and the 'survivability' of a SUDS component. The development of STTAT as a response to the requirements of the Water Framework Directive is explored, the individual scores being given in tabular format for receiving water and catchment risks. Treatment scores are proposed for single SUDS components as well as multiple components within treatment trains. STTAT has been tested on a range of sites, predominantly in Scotland where both development and receiving water information was known. The operational tool in use by SEPA is presented.

Changes in muscle strength and pain in response to surgical repair of posterior abdominal wall disruption followed by rehabilitation.

BACKGROUND: Posterior abdominal wall deficiency (PAWD) is a tear in the external oblique aponeurosis or the conjoint tendon causing a posterior wall defect at the medial end of the inguinal canal. It is often known as sportsman's hernia and is believed to be caused by repetitive stress. OBJECTIVE: To assess lower limb and abdominal muscle strength of patients with PAWD before intervention compared with matched controls; to evaluate any changes following surgical repair and rehabilitation. METHODS: Sixteen subjects were assessed using a questionnaire, isokinetic testing of the lower limb strength, and pressure biofeedback testing of the abdominals. After surgery and a six week rehabilitation programme, the subjects were re-evaluated. A control group were assessed using the same procedure. RESULTS: Quadriceps and hamstrings strength was not affected by this condition. A deficit hip muscle strength was found on the affected limb before surgery, which was significant for the hip flexors (p = 0.05). Before surgery, 87% of the patients compared with 20% of the controls failed the abdominal obliques test. Both the injured and non-injured sides had improved significantly in strength after surgery and rehabilitation. The strength of the abdominal obliques showed the most significant improvement over the course of the rehabilitation programme. CONCLUSIONS: Lower limb muscle strength may have been reduced as the result of disuse atrophy or pain inhibition. Abdominal oblique strength was deficient in the injured patients and this compromises rotational control of the pelvis. More sensitive investigations (such as electromyography) are needed to assess the link between abdominal oblique function and groin injury.

Interventional radiology in palliative medicine.

Substantial developments in interventional radiology over the last two decades have resulted in the introduction of new methods of treatment for patients with advanced malignancy. These new minimally invasive techniques avoid the need for prolonged hospital inpatient care.

Superior vena caval obstruction managed by the Gianturco Z Stent.

Twenty patients with superior vena caval obstruction (SVCO) due to malignancy were managed using the Gianturco Z Stent. Three patients had adjunctive thrombolysis. The primary clinical success was 90% (18/20 patients). Thirteen patients were free of SVCO to death or follow-up without re-intervention (primary patency = 65%). Three patients had re-intervention for recurrent symptoms, two successfully (secondary long-term patency = 75%). Stenting of the SVC is a valuable, under-used technique for the symptomatic relief of superior vena caval obstruction.

Case report: pelvic pain syndrome--successful treatment of a case by ovarian vein embolization.

Pelvic pain syndrome, without an apparent organic cause, is a common gynaecological complaint. Investigations, including laparoscopy are frequently negative but ovarian venography has demonstrated that pelvic varices are a consistent finding in these patients. The aetiology of pelvic varices has been the subject of debate, but it has recently been suggested that the primary problem is venous reflux in dilated, incompetent ovarian veins. Surgical ligation of the ovarian veins has been used effectively in small series of patients with this condition. We report a patient with the clinical and radiological features of this syndrome in which treatment by bilateral ovarian venous embolization produced prolonged symptomatic relief.

Case report: the ultrasound and Doppler appearances of pelvic varices.

Dilatation of the veins of the broad ligament and ovarian plexi cause a very specific clinical entity called the pelvic congestion or pelvic pain syndrome. The ultrasound and Doppler appearances of this condition are unique and should be easily recognized. We describe these appearances in one patient and review the literature.

Malignant 'angiodysplasia'.

Four patients with chronic gastrointestinal blood loss of obscure aetiology were investigated by visceral angiography. All showed angiographic abnormalities in the caecum with characteristic features seen in angiodysplasia as well as other conditions such as inflammatory bowel disease, carcinoma. All four patients had a malignant cause for their angiographic appearance. This paper stresses the importance of reviewing previous examinations before accepting a diagnosis of angiodysplasia. The angiographic features of contrast pooling on the anti-mesenteric border of the caecum or ascending colon, a dilated intramural vein and early filling of a draining vein imply that serious pathology is present.