Can levator avulsion be repaired surgically? A prospective surgical pilot study.

INTRODUCTION AND HYPOTHESIS: Avulsion of the puborectalis muscle from its bony insertion is common in women presenting with prolapse. We present a simple vaginal technique for levator reconstruction. METHODS: This is a prospective surgical pilot study comprising 17 patients enrolled to undergo levator repair in the context of prolapse surgery. This was performed through a lateral colpotomy at the level of the hymen using a mesh patch for reinforcement. RESULTS: We performed 20 levator repairs in 17 women (three bilateral). There were no intraoperative complications. Recovery was unremarkable in all cases. Results are given for a mean follow-up of 1.3 years. Most (13/17, 76 %) women were satisfied with the outcome. Six patients complained of symptoms of recurrent prolapse, three of de novo dyspareunia, and four of pain related to the repair site on palpation. There were two mesh erosions, one of which healed with oestrogen treatment. Prolapse recurrence beyond the hymen was observed in five patients. The mean hiatal area on Valsalva was reduced from 36.84 cm(2) to 30.71 cm(2) (P=0.001). CONCLUSIONS: Direct surgical repair of a levator avulsion is feasible at the time of prolapse surgery. However, its effect on prolapse recurrence and hiatal dimensions is relatively disappointing, suggesting that there often is microscopic trauma and functional muscle impairment in addition to the avulsion.

Convolutional neural network propagation on electroencephalographic scalograms for detection of schizophrenia.

OBJECTIVE: Electroencephalographic analysis (EEG) has emerged as a powerful tool for brain state interpretation. Studies have shown distinct deviances of patients with schizophrenia in EEG activation at specific frequency bands. METHODS: Evidence is presented for the validation of a Convolutional Neural Network (CNN) model using transfer learning for scalp EEGs of patients and controls during the performance of a speeded sensorimotor task and a working memory task. First, we trained a CNN on EEG data of 41 schizophrenia patients (SCZ) and 31 healthy controls (HC). Secondly, we used a pretrained model for training. Both models were tested in an external validation set of 15 SCZ, 16 HC, and 12 first-degree relatives. RESULTS: Using the layer-wise relevance propagation on the classification decision, a heatmap was produced for each subject, specifying the pixel-wise relevance. The CNN model resulted in the first case in a balanced accuracy of 63.7% and 81.5% in the second case, on the external validation test 64.5% and 83.2%, respectively. CONCLUSIONS: The theta and alpha frequency bands of the EEG signals had significant relevance to the CNN classification decision and predict the first-degree relatives indicating potential heritable functional deviances. SIGNIFICANCE: The proposed methodology results in important advancements for the identification of biomarkers in schizophrenia heritability.

Identification of voxel-based texture abnormalities as new biomarkers for schizophrenia and major depressive patients using layer-wise relevance propagation on deep learning decisions.

Non-segmented MRI brain images are used for the identification of new Magnetic Resonance Imaging (MRI) biomarkers able to differentiate between schizophrenic patients (SCZ), major depressive patients (MD) and healthy controls (HC). Brain texture measures such as entropy and contrast, capturing the neighboring variation of MRI voxel intensities, were computed and fed into deep learning technique for group classification. Layer-wise relevance was applied for the localization of the classification results. Texture feature map of non-segmented brain MRI scans were extracted from 141 SCZ, 103 MD and 238 HC. The gray level co-occurrence matrix (GLCM) was calculated on a voxel-by-voxel basis in a cube of voxels. Deep learning tested if texture feature map could predict diagnostic group membership of three classes under a binary classification (SCZ vs. HC, MD vs. HC, SCZ vs. MD). The method was applied in a repeated nested cross-validation scheme and cross-validated feature selection. The regions with the highest relevance (positive/negative) are presented. The method was applied on non-segmented images reducing the computation complexity and the error associated with segmentation process.

Knowledge, attitude and practises of dentists towards oral health care during pregnancy: A cross sectional survey in New South Wales, Australia.

BACKGROUND: Studies internationally show a lack of consensus among dentists regarding perinatal oral health yet no study in Australia has explored the perceptions of dentists in this area. This study aims to determine the knowledge, perceptions and practises of dentists in New South Wales (NSW), Australia, about perinatal oral health. METHODS: An online survey was distributed to 1357 members of the Australian Dental Association (NSW) and 185 (13.4%) completed surveys were returned. RESULTS: Most dentists (99%) stated that pregnant women should receive a dental check, yet only 20% agreed that there was a good understanding among health professionals on this topic. Dentists were aware of safe dental practises during pregnancy but had limited knowledge about the association between periodontal disease and birth outcomes. Dentists were more likely to advise pregnant women to delay dental visits when there was a perceived lack of knowledge of the risks involved (odds ratio, 2.157) or were concerned about providing treatment without consent from their general practitioner (odds ratio, 2.449). Most dentists (95.7%) stated that they wanted further information about dental care during pregnancy. CONCLUSIONS: Findings suggest a need for continuing education for dentists and practise guidelines on perinatal oral health. Further research with a national sample is recommended to confirm these findings.

Possible role of RAC-GTPase-activating protein in the termination of superoxide production in phagocytic cells.

The mechanism leading to the termination of superoxide production of phagocytes is poorly understood. The aim of the present study was to investigate the involvement of the active (GTP-bound) form of the GTP-binding proteins in maintaining continuous electron transport through the reduced nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex. Activation of the enzyme was carried out under in vitro conditions and a shift from the active to the inactive form of the GTP-binding protein was attained (i) by addition of an excess of GDP to the assembled enzyme complex or (ii) by variation of the Rac-GTPase activating (Rac-GAP) capacity of the constituents of the cell-free system. Significant inhibition of O2*- production was observed when guanine dinucleotides were added after the assembly of the active enzyme complex. The effect was specific for GDP and GDP,S whereas ADP, CDP and UDP were ineffective. GTP was significantly less efficient in inducing superoxide production in a cell-free system containing endogenous GAP activity than in a system devoid of GAP activity. It is suggested that the active, GTP-bound form of Rac is required for sustained catalytic function and Rac-GAP proteins are involved in the downregulation of the oxidase.

Clonidine hydrochloride--a safe and effective antihypertensive agent in pregnancy.

A prospective, double-blind, randomized controlled trial was carried out, comparing alpha-methyldopa and clonidine hydrochloride in 100 pregnant women with hypertension. There was no difference in hypotensive effect or reported maternal side effects with either agent. There was one neonatal loss in each group (98% survival). Neither drug caused clinically significant hypotension nor rebound hypertension in the neonates. Clonidine hydrochloride, like methyldopa, appears to be a safe antihypertensive agent in pregnancy.

PP034. Cardiovascular outcomes remote from pregnancy in women with HDP: 23-32years following delivery.

INTRODUCTION: Cardiovascular disease (CVD) is a leading cause of mortality worldwide in women aged >54years. There is a strong association between HDP and the development of hypertension in later life. OBJECTIVES: To ascertain the current health profile of some of the women who were diagnosed with a HDP and participated in a trial during the time period of 1980-1989 and to examine the association between the two. METHODS: Women who delivered at a major teaching hospital during the designated time period and who were enrolled at that time in trials examining HDP treatments and outcomes were invited to participate in a health status evaluation. Their medical histories, time sequenced blood pressure readings, urinalysis, BMI and pulse wave analysis were compared using standard statistical techniques of Chi-square analysis and Student's t-tests obtained from IBM SPSS v.19™. RESULTS: Thirty-nine women from the trials were available for follow-up. Of these women, 85% had current CVD, of which 88% had hypertension, 59% hypercholesterolaemia and 3% had experienced a CVA. Compared to the general female population of 22% for CVD this equates to a RR of 7.2 (CI 95% 3.042-15.13). CONCLUSION: HDP is associated with an increased risk of CVD compared to the general female population. Women who experience HDP in their pregnancy should be monitored regularly due to an increased risk of CVD and potentially early onset of the disease.

PP102. Hypertension in pregnancy and long term cardiovascular mortality outcomes.

INTRODUCTION: Hypertensive Disorders of Pregnancy (HDP) remain a leading cause of maternal morbidity and mortality worldwide affecting up to 10% of all pregnancies. Previous works inform that long term morbidity includes cardiovascular disease, including ischaemic heart disease, stroke and hypertension. The extent of long term mortality amongst women distant from the primary pregnancy event is not known. OBJECTIVES: To determine mortality rates and cause of death for women who had hypertension during pregnancy between the years 1980-86. METHODS: Women who had hypertension during pregnancy were identified via by ICD-9 coding. From record examination, there was an existing cohort of women who participated in clinical trials at Royal Prince Alfred Hospital in the 1980's. These trials included placebo controlled for blood pressure in pregnancy. The deaths among this cohort were identified by the NSW Registry of Birth Deaths and Marriages. The causes of death were verified from the International Classification of Diseases versions depending upon the year of death. RESULTS: There were a total of 332 women identified as participating in the various trials between the years 1980-86. Of these, there were 17 deaths reported by 2011. This gives an overall mortality rate of 5.1%. Five of these deaths were due to CVD. This equates to an RR of 44.6 (CI 95% 17.43-112.56). CONCLUSION: Women with hypertensive disorders in pregnancy have a higher mortality rate compared to the general female population. Further research is required to determine the relationship between HDP and future hypertension and whether the type of treatment and management women receive with HDP effects their risk of future long term health outcomes.

PP033. High blood pressure in pregnancy: an indicator of future health outcomes.

INTRODUCTION: Hypertensive disorders of pregnancy (HDP) remain a leading cause of maternal and perinatal morbidity and mortality worldwide. In Australia approximately 10% of all pregnancies are affected by HDP. There is growing evidence that endothelial damage caused by HDP remains after pregnancy and has long term consequences on maternal health. OBJECTIVES: The aim of our research was to determine the association between HDP and risk of having high blood pressure in later life. METHODS: Self-reported data regarding a physician's diagnosis of HDP and of high blood pressure later in life were obtained from women recruited from the 45 and Up Study, Australia. Relative risks (converted from odds ratios) and 99% confidence intervals were estimated using logistic regression, adjusting for demographic and lifestyle characteristics. RESULTS: A total of 82,164 women were included in the study, of which 9,845 reported having HDP. Women who had HDP had a significantly increased risk of having high blood pressure later in life compared to women who did not have HDP (adjusted relative risk of 2.05, 99% CI 1.99-2.11, p<0.001). The results showed that women who had HDP develop high blood pressure 6.3 years (99% CI 5.85-6.66, p<0.001) earlier compared to women without HDP. CONCLUSION: Women who have HDP are at a greater risk of future onset of high blood pressure compared to women who have a healthy pregnancy. Women with HDP should be monitored closely in the years following pregnancy for early identification and intervention of high blood pressure.

An efficient route from trifluoroacetates to water soluble free amines using Diaion HP-20.

A series of polybasic lysine and ornithine derivatives were synthesised as trifluoroacetate salts. Attempts to prepare their free amines according to standard methodology were not successful due to the excellent water solubility of these compounds. Free amines were however efficiently obtained if the column with Diaion HP-20 adsorbent was loaded with the trifluoroacetate and 1% NaHCO(3) aq was passed, followed by elution of free amine with methanol.

The prevention of prematurity.

The prevention of prematurity requires identification of the patients most likely to go into labour prematurely and early recognition of threatened premature labour. There are unfortunately few clinical signs to help identify these patients, but certain features in the history are helpful. As soon as premature labour is diagnosed, energetic and active treatment with corticosteroids to advance pulmonary maturity and uterine suppression should be instituted. It is important to bear in mind that these patients should be managed in units, where not only is such treatment feasible, but neonatal intensive care is available, if labour cannot be suppressed.

The effect of obesity on the outcome of successful surgery for genuine stress incontinence.

In a study of 190 patients with genuine stress incontinence, 91 patients were of normal weight, 66 overweight and 33 obese as determined by their Body Mass Index at the time of operation which was either a colposuspension (143) or a silastic sling insertion (47). Body mass index was found to significantly alter the outcome.

The use of prolonged bladder distension in the treatment of intractable urinary incontinence in females with detrusor instability.

Fifty patients suffering from detrusor instability who failed to respond to anticholinergic treatment were treated with prolonged bladder distension. Twelve months after treatment 9 were symptom free, 15 improved and 26 remained symptomatically unchanged. Extraperitoneal bladder rupture occurred in 2 patients.

Acute severe hypertension in pregnancy.

Acute severe hypertension is a significant cause of fetal and maternal morbidity and mortality. The rationale for treatment and the various modes of management are reviewed. The importance of timely delivery is stressed.

Incisionless cystourethropexy--the Intac device--an initial experience.

Our aim was to evaluate a new minimally invasive device for the treatment of genuine stress incontinence in women by both objective and subjective measures of outcome. Fifteen women with Type I or Type II urinary stress incontinence were treated with a new per vaginal bone anchor device designed to fix periurethral tissues to the pubic bone. No patients had significant operative morbidity. After 6-13 months a follow-up questionnaire and repeat urodynamic testing was performed for all the women. Subjectively 73% of patients had improvement in symptoms and on urodynamic testing 53% of patients were cured.

Colposuspension for the treatment of female urinary incontinence.

Between June 1, 1983 and June 30, 1988, 174 patients with stress incontinence were treated with a colposuspension operation; 144 patients were cured, 30 remained wet. Sixteen patients who remained wet had detrusor instability; 9 of these were cured by anticholinergic medications. Of 25 patients who had dual pathology 19 were cured. Seventy nine patients had urinary tract infections. Two patients had ureteric obstruction due to kinking; it is postulated that this can be an infrequent and sometimes unavoidable complication.

Experience with silastic slings for female urinary incontinence.

Between September 1, 1985 and December 31, 1987, 54 patients with stress urinary incontinence were treated with a reinforced silastic sling using an abdominovaginal approach; 42 patients were cured, two improved and nine were the same or worse. Five patients who are continent required periodic intermittent self-catheterization. Eight patients developed detrusor instability postoperatively. One patient had to have the sling removed due to a persistent sinus. Fifteen patients had to have the sling adjusted.