Age, Gender, and Liver Enzyme Impact Hospital Stay in COVID-19 Minority Patient with Cancer in the USA: Does Race Matters in the Pandemic?

Patients with cancer are known to have a poor prognosis when infected with SARS-CoV-2 infection. We aimed in this study to assess health outcomes in COVID-19 patients with different cancers in comparison to non-cancer COVID-19 patients from different centers in the United States (US). We evaluated medical records of 1,943 COVID-19 Cancer patients from 3 hospitals admitted between December 2019 to October 2021 and compared them with non-cancer COVID-19 patients. Among 1,943 hospitalized COVID-19 patients, 18.7% (n=364) have an active or previous history of cancer. Among these 364 cancer patients, 222 were African Americans (61.7%) and 121 were Caucasians (33.2%). Cancer patients had significantly longer hospitalization compared to controls (8.24 vs 6.7 days). Overall, Lung cancer is associated with high mortality. Patients with a previous history of cancer were more prone to death (p=0.04) than active cancer patients. In univariate and multivariate analyses, predictors of death among cancer patients were male sex, older age, presence of dyspnea, elevated troponin, elevated AST (0.001) and ALT (0.05), low albumin (p=0.04) and mechanical ventilation (p=0.001). Patients with a previous history of cancer were more prone to death when compared to active cancer COVID-19 patients. Early recognition of cancer COVID-19 patients' death-associated risk factors can help determine appropriate treatment and management plans for better prognosis and outcome.

Feasibility and reproducibility of new technique for measurement of transverse diameter of levator ani muscle hiatus using two-dimensional transperineal ultrasound in nulliparous women at term

OBJECTIVES

The aim of the present study was twofold; firstly to develop and describe the technique for measurement of the transverse diameter of the levator ani muscle hiatus (TD) in the coronal view using 2D transperineal ultrasound (TPUS) in nulliparous women at term of pregnancy. Secondly, we aimed to assess the feasibility and reproducibility of 2D TPUS assessment of TD, in addition to the inter-method agreement between 2D TPUS and the 3D measurement of TD on the axial plane, the latter considered as the gold standard in nulliparous women at term of pregnancy.

METHODS

For the aim of the study, we recruited a group of nulliparous women at term of pregnancy before the onset of labor. The study was conducted in two phases: phase 1 involved developing and describing the 2D TPUS technique for measuring TD, while phase 2 focused on assessing the technique's feasibility, reproducibility, and inter-method agreement. In phase 1, we enrolled 30 women. Each woman underwent the acquisition of a 3D TPUS volume, which was analyzed using the multiplanar mode to identify the appearance of the lateral borders of the levator ani muscle at the level of the plane of minimal hiatal dimensions in the coronal plane. These borders were used as landmarks for TD measurement. Additionally, we measured the distance between the line indicating TD and the center of the urethra in the axial view. Phase 2 involved recruiting 100 women. Each woman underwent the acquisition of three 2D TPUS clips in the coronal plane, each encompassing a sweep of the entire levator hiatus, and a 3D volume, all obtained during rest. On the 2D clips, TD was measured twice by one operator and once by another operator. TD was measured once in the 3D volume in the axial plane, considered the gold standard. Each operator was blinded to all other measurements during their assessments. We analyzed intraobserver, interobserver, and intermethod (2D vs. 3D) reproducibility. Bland-Altman analysis was conducted, and Levene's W0 and Student t-tests were performed to explore clinical factors that might contribute to systematic differences.

RESULTS

In phase 1, we successfully identified the landmarks denoting the lateral borders of TD in the coronal view. These appeared as two symmetrical hypoechoic indentations located at the inner border of the hyperechoic structure of the levator ani muscle, at the point of maximum distance between the two sides of the levator ani muscle. Additionally, the distance between the urethra and the plane where TD was measured using 3D TPUS in the axial plane had a median of 4 mm and varied from 0 to 9 mm. This enabled us to describe the method for assessing TD in the coronal plane through the use of 2D TPUS. In phase 2, TD was successfully measured in all 2D and 3D acquisitions from the entire group of 100 women. The analyses for intraobserver, interobserver reproducibility, and intermethod comparison (2D vs. 3D) revealed almost perfect agreement in TD measurements using 2D TPUS, with Intraclass Correlation Coefficients (ICCs) of 0.95 (95% CI, 0.92 to 0.96), 0.87 (95% CI, 0.78 to 0.92), and 0.85 (95% CI, 0.78 to 0.90), respectively. The average differences between measurements were 0.1 mm for intraobserver, 1.0 mm for interobserver, and 0.2 mm for intermethod repeatability. No systematic differences were observed in any of the measurement sets, except in the inter-operator analysis, although the difference was clinically insignificant (38.2 vs. 37.1 mm, P= 0.01). None of the examined clinical factors (maternal body mass index and maternal age) exhibited a statistically significant impact on intraobserver, interobserver, or intermethod reliability.

CONCLUSIONS

Utilizing our described technique to measure the transverse diameter of the levator hiatus in the coronal view using 2D TPUS is not only feasible but also highly reproducible and accurate in nulliparous women at term of pregnancy. Moreover, it yields measurements that are comparable to those obtained in the reconstructed axial plane generated by 3D TPUS. This article is protected by copyright. All rights reserved.

Time to focus on the role of the pelvic floor in vaginal delivery

Linked article: This Correspondence comments on Preuss et al. Click here to view the article.

All that Glitters is Not Gold: Examining Cost Effectiveness Analyses in Radiation Oncology

PURPOSE/OBJECTIVE(S)

Cost effectiveness analyses (CEA) provide data for health policy decisions in resource constrained environments. These are important in Radiation Oncology as infrastructure and delivery costs increase and indications expand. The purpose of this study was to systematically review methodologic quality and trends in CEAs involving radiotherapy (RT).

MATERIALS/METHODS

A systematic review was performed on cost effectiveness/utility studies involving RT, querying PubMed and Embase from inception to September 2020. Non-English, reviews, abstracts and cost-only studies were excluded. Independent reviewers screened and abstracted study demographics, economic parameters and methodological details.

RESULTS

After screening 1652 abstracts, 214 met criteria. The first publication was in 1995, and more than half (n = 113, 53%) were published after 2014. Author institutions were from North America (n = 128, 60%), Europe (n = 49, 23%) and Asia (n = 30, 14%) with most reporting in US$ (n = 143, 67%). A majority utilized a decision model (n = 164, 77%), healthcare payer perspective (n = 171, 80%) and a finite time horizon (n = 108, 50%). Publications spanned 96 unique journals, most commonly International Journal of Radiation and Oncological Biology and Physics (n = 35, 16%). Treatment intent was curative in 171 studies. Disease sites included breast (n = 34, 16%), genitourinary (n = 31, 14%), and gastrointestinal (n = 31, 14%). RT was mostly used as primary treatment (n = 144, 67%), followed by adjuvant (n = 70, 33%) and neoadjuvant (n = 10, 5%). Emerging topics included stereotactic RT (n = 45, 21%), immunotherapy (n = 6, 3%), oligometastasis (n = 4, 2%), and heavy particles (n = 23, 11%). RT was compared to other RT (n = 136, 64%), surgery (n = 43, 20%), drugs (n = 14, 7%) and observation (n = 31, 17%). Incomplete reporting was common. Missing elements included analysis perspective (n = 13, 6%), time horizon (n = 38, 18%), discounting of utilities (n = 71, 33%) or costs (n = 54, 25%), and willingness-to-pay threshold (n = 59, 28%). Furthermore, 27 studies did not perform sensitivity analyses, 36 did not evaluate incremental cost-effectiveness ratio and only 60 explicitly utilized recognized reporting guidelines. Conflict of interest statements were found in 63%, with sponsor statements in 59%; 25% were industry sponsors. Outcome parameters were obtained from primary (author institution/trial data) sources in 33%, including randomized trials (RCTs) (n = 20, 9%), retrospective data (n = 20, 9%) and population data (n = 9, 4%). The remainder utilized secondary sources including RCTs (n = 71, 33%), retrospective data (n = 35, 16%) or meta-analyses (n = 11, 5%). Outcomes included quality adjusted life years (n = 158, 74%), life-years (n = 30, 14%) or toxicity (n = 26,12%). 31% utilized author generated utilities; of literature derived only 49% were matched to disease and clinical context.

CONCLUSION

While CEAs are increasingly common in RT, reporting and methodologic rigor must improve. Greater use of published guidelines will improve data quality for decision makers.

Identifying discrepancies between clinical practice and evidence-based guideline in recurrent pregnancy loss care, a tool for clinical guideline implementation

BACKGROUND

Practice variation in recurrent pregnancy loss (RPL) care is common. International guidelines vary in their recommendations for the management of RPL couples, which could lead to an increase of cross border reproductive care. Currently, the Dutch RPL guideline is being adapted from the European Society for Human Reproduction and Embryology (ESHRE) guideline. We aim to identify discrepancies between RPL guidelines and RPL practice. These discrepancies could be considered in the development of a new guideline and implementation strategies to promote adherence to new recommendations.

METHODS

A nationwide survey on the management of RPL patients was conducted across all 107 hospital-based obstetrics and gynaecology practices in the Netherlands. The survey was sent via the Dutch Society for Obstetricians and Gynaecologists to all affiliated clinicians. The questionnaire consisted of 36 questions divided in four sections: clinician's demographics, RPL definition, investigations and therapy. The data were compared to the recommendations given by the Dutch national guideline and the most recent guideline of the ESHRE.

RESULTS

All hospital-based practices (100%; n = 107) filled in the online questionnaire. The majority of respondents defined RPL similarly, as two or more pregnancy losses (87.4%), not obligatory consecutive (93.1%). More than half of respondents routinely perform thrombophilia screening ( 58%), although not advised by the ESHRE, while thyroid function (57%), thyroid auto-immunity (27%) and β2-glycoprotein antibodies (42%) in the context of antiphospholipid syndrome (APS) are recommended but investigated less often. Regarding parental karyotyping, 20% of respondents stated they always perform parental karyotyping, without prior risk assessment. because of RPL. Treatment for hereditary thrombophilia was frequently (43.8% (n = 137)) prescribed although not recommended. And finally, a considerable part (12-16%) of respondents prescribe medication in case of unexplained RPL.

CONCLUSION

While many clinicians perform investigations recommended by the ESHRE, there is a considerable variation of RPL practice in the Netherlands. We identified discrepancies between RPL guidelines and RPL practice, providing possibilities to focus on multifaceted implementation strategies, such as educational intervention, local consensus processes and auditing and feedback. This will improve the quality of care provided to RPL patients and may diminish the necessity felt by patients to turn to multiple opinions or cross border reproductive care.

Epidemiology and risk factors of colorectal cancer in Syria: a single-center retrospective study

OBJECTIVE

Colorectal cancer represents the third most common malignancy and the second leading cause of cancer deaths worldwide. Many factors contribute to the risk of developing colorectal carcinoma including diet, lifestyle, age, and genetic abnormalities.  Recent findings have shown a considerable increase in the incidence rate of CRC in developing countries. However, there is little information regarding its incidence in the Middle East countries, including Syria. With our manuscript we aimed at presenting the first large epidemiological study regarding colorectal carcinoma incidence in Syria.

PATIENTS AND METHODS

We conducted a retrospective study on colorectal carcinoma cases at our institution from 2014 to 2018. The data include the cases that were diagnosed and recorded based on multiple parameters including gender, age, year of diagnosis, city of origin, and profession.

RESULTS

The number of colorectal cancer cases was 1,117 out of 13,589 cases of all malignant tumors recorded from 2014 to 2018, with an annual average incidence of 8.2%. There was a statistically significant difference in CRC cases according to age and gender. We also found a statistically significant difference according to physical activity and occupation.

CONCLUSIONS

These results demonstrate that risk factors related to colorectal cancer incidence in Syria mainly include male sex, age over 50 years old, and occupation with no physical activity.

The extrapyramidal syndromes of chronic kidney disease and dialysis (EPS-CKDD): diagnostic criteria, risk factors and prognosis

BACKGROUND

Acute extrapyramidal movement disorders in dialysis patients are rare, inconsistently defined and have uncertain aetiology and prognosis.

AIM

Define diagnostic criteria, prognosis and risk factors.

DESIGN AND METHODS

Retrospective case series review of 20 patients (14 female, mean age 62 years) receiving dialysis for a median of 15 (interquartile range 4-35) months who presented with acute parkinsonism (AP = 11) or chorea/athetosis (CA = 9).

RESULTS

All patients had type 2 diabetes (HbA1c 6.8 ± 1.0) and had received metformin. Lactic acidosis was present in 2 patients at presentation and serum lactate was elevated in 7/15 patients tested. No patient had abnormal copper or thyroid metabolism and 5/8 patients tested returned marginal abnormalities in heavy metal screening. Magnetic resonance imaging (MRI) revealed characteristic bilateral symmetric T2 hyperintensity of the basal ganglia (BG), predominantly putamen and globus pallidus (the lentiform nucleus) and more extensive involvement of the external and internal capsules in patients with AP presentation. Post-mortem demonstrated cytotoxic necrosis of the BG. Therapy included thiamine, intensive dialysis and cessation of metformin. Two patients died acutely, nine recovered and nine had residual symptoms. Median survival did not differ by presentation: AP 24 [95% confidence interval (CI) 21-27] and CA 33 (95% CI 32-35) months, P = 0.21.

CONCLUSIONS

There are two distinct clinical extrapyramidal movement disorders associated with specific diagnostic MRI imaging that support the diagnosis of the extrapyramidal syndromes of chronic kidney disease and dialysis. The associations with diabetes, metformin and metabolic acidosis suggest a common pathogenic mechanism but require additional study. Early recognition and treatment may improve outcomes.

External validation of a frequently used prediction model for ongoing pregnancy in couples with unexplained recurrent pregnancy loss

STUDY QUESTION

What is the predictive performance of a currently recommended prediction model in an external Dutch cohort of couples with unexplained recurrent pregnancy loss (RPL)?

SUMMARY ANSWER

The model shows poor predictive performance on a new population; it overestimates, predicts too extremely and has a poor discriminative ability.

WHAT IS KNOWN ALREADY

In 50-75% of couples with RPL, no risk factor or cause can be determined and RPL remains unexplained. Clinical management in RPL is primarily focused on providing supportive care, in which counselling on prognosis is a main pillar. A frequently used prediction model for unexplained RPL, developed by Brigham et al. in 1999, estimates the chance of a successful pregnancy based on number of previous pregnancy losses and maternal age. This prediction model has never been externally validated.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study consisted of 739 couples with unexplained RPL who visited the RPL clinic of the Leiden University Medical Centre between 2004 and 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Unexplained RPL was defined as the loss of two or more pregnancies before 24 weeks, without the presence of an identifiable cause for the pregnancy losses, according to the ESHRE guideline. Obstetrical history and maternal age were noted at intake at the RPL clinic. The outcome of the first pregnancy after intake was documented. The performance of Brigham's model was evaluated through calibration and discrimination, in which the predicted pregnancy rates were compared to the observed pregnancy rates.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort included 739 women with a mean age of 33.1 years (±4.7 years) and with a median of three pregnancy losses at intake (range 2-10). The mean predicted pregnancy success rate was 9.8 percentage points higher in the Brigham model than the observed pregnancy success rate in the dataset (73.9% vs 64.0% (95% CI for the 9.8% difference 6.3-13.3%)). Calibration showed overestimation of the model and too extreme predictions, with a negative calibration intercept of -0.46 (95% CI -0.62 to -0.31) and a calibration slope of 0.42 (95% CI 0.11-0.73). The discriminative ability of the model was very low with a concordance statistic of 0.55 (95% CI 0.51-0.59). Recalibration of the Brigham model hardly improved the c-statistic (0.57; 95% CI 0.53-0.62).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study in which only the first pregnancy after intake was registered. There was no time frame as inclusion criterium, which is of importance in the counselling of couples with unexplained RPL. Only cases with a known pregnancy outcome were included.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study externally validating the Brigham prognostic model that estimates the chance of a successful pregnancy in couples with unexplained RPL. The results show that the frequently used model overestimates the chances of a successful pregnancy, that predictions are too extreme on both the high and low ends and that they are not much more discriminative than random luck. There is a need for revising the prediction model to estimate the chance of a successful pregnancy in couples with unexplained RPL more accurately.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used and no competing interests were declared.

TRIAL REGISTRATION NUMBER

N/A.

1476 North Wales Vascular Surgery Zoom Webinar Teaching Programme for Medical Students and Junior Doctors

Aim

Surgical Education is now more widely delivered on virtual platforms due to the COVID-19 pandemic. Due to centralisation of Vascular Surgery services in North Wales to Glan Clwyd Hospital (Central), Medical Students, Junior Doctors and General Surgical Registrars have reduced exposure to the speciality and the management of common cases in neighbouring hospitals (East and West). Subsequently, we developed a regional virtual teaching programme to help bridge gaps in knowledge and to instil confidence when providing a service.

Method

We developed a 4-part didactic webinar educational programme which covered parts of the medical undergraduate and MRCS curricula pertaining to Vascular Surgery. Under/Postgraduate educational leads from Central, East and West were contacted to promote our programme. Webinars were delivered on ZOOM video conferencing once weekly throughout December 2020. Feedback forms were collected on Google Forms™ and used 5-point Linkert scales to grade responses and analysis of data was carried out on Microsoft Excel®.

Results

186 feedback forms were collected and respondents reported significant improvements in knowledge in each of the subjects covered: [1] Abdominal Aortic Aneurysms - (2.59±1.07/5 to 4.23±0.65/5, p = <0.0001, n = 60), [2] Acute Limb Ischaemia – (2.55±1.11/5 to 4.21±0.72/5, p = <0.0001, n = 42); [3] Chronic Limb Ischaemia (2.57±1.03/5 to 4.23±0.77/5, p = <0.0001, n = 35); [4] Vascular Emergencies (2.94±1.28/5 to 4.37±0.63/5, p = <0.0001, n = 49). Overall topic interest, presentational skills and clinical usefulness was also rated highly.

Conclusions

Through this virtually delivered regional teaching programme, we successfully enhanced Vascular Surgery knowledge and addressed the educational needs of Medical Students and Junior Doctors across North Wales.

Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal

OBJECTIVE

To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA).

METHODS

Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W₀ test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements.

RESULTS

Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability.

CONCLUSIONS

BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

P–419 On prognosis after unexplained recurrent pregnancy losses (RPL); a systematic review and external validation of clinical prediction models

Study question

Which models that predict pregnancy outcome in couples with unexplained RPL exist and what is the performance of the most used model?

Summary answer

We identified seven prediction models; none followed the recommended prediction model development steps. Moreover, the most used model showed poor predictive performance.

What is known already

RPL remains unexplained in 50–75% of couples For these couples, there is no effective treatment option and clinical management rests on supportive care. Essential part of supportive care consists of counselling on the prognosis of subsequent pregnancies. Indeed, multiple prediction models exist, however the quality and validity of these models varies. In addition, the prediction model developed by Brigham et al is the most widely used model, but has never been externally validated.

Study design, size, duration

We performed a systematic review to identify prediction models for pregnancy outcome after unexplained RPL. In addition we performed an external validation of the Brigham model in a retrospective cohort, consisting of 668 couples with unexplained RPL that visited our RPL clinic between 2004 and 2019.

Participants/materials, setting, methods

A systematic search was performed in December 2020 in Pubmed, Embase, Web of Science and Cochrane library to identify relevant studies. Eligible studies were selected and assessed according to the TRIPOD) guidelines, covering topics on model performance and validation statement. The performance of predicting live birth in the Brigham model was evaluated through calibration and discrimination, in which the observed pregnancy rates were compared to the predicted pregnancy rates.

Main results and the role of chance

Seven models were compared and assessed according to the TRIPOD statement. This resulted in two studies of low, three of moderate and two of above average reporting quality. These studies did not follow the recommended steps for model development and did not calculate a sample size. Furthermore, the predictive performance of neither of these models was internally- or externally validated.

We performed an external validation of Brigham model. Calibration showed overestimation of the model and too extreme predictions, with a negative calibration intercept of –0.52 (CI 95% –0.68 – –0.36), with a calibration slope of 0.39 (CI 95% 0.07 – 0.71). The discriminative ability of the model was very low with a concordance statistic of 0.55 (CI 95% 0.50 – 0.59).

Limitations, reasons for caution

None of the studies are specifically named prediction models, therefore models may have been missed in the selection process. The external validation cohort used a retrospective design, in which only the first pregnancy after intake was registered. Follow-up time was not limited, which is important in counselling unexplained RPL couples.

Wider implications of the findings: Currently, there are no suitable models that predict on pregnancy outcome after RPL. Moreover, we are in need of a model with several variables such that prognosis is individualized, and factors from both the female as the male to enable a couple specific prognosis.

Trial registration number

Not applicable

Fetal head progression and regression on maternal pushing at term and labor outcome

OBJECTIVES

The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing.

METHODS

This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed.

RESULTS

Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission.

CONCLUSIONS

In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia.

METHODS

This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated.

RESULTS

Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01).

CONCLUSIONS

In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Transperineal ultrasound assessment of maternal pelvic floor at term and fetal head engagement

OBJECTIVES

To evaluate the association between pelvic floor dimensions in nulliparous women at term and fetal head engagement, as assessed by transperineal ultrasound.

METHODS

This was a prospective observational study of nulliparous women at term. Before the onset of labor, transperineal ultrasound was used to measure the anteroposterior diameter (APD) of the levator hiatus and the angle of progression (AoP) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver (before and after visual feedback). We assessed the correlation between pelvic floor static and dynamic dimensions (levator hiatal APD and levator ani muscle coactivation) and AoP, which is an objective index of fetal head engagement.

RESULTS

In total, 282 women were included in the analysis. Among these, 211 (74.8%) women had a vaginal delivery while 71 (25.2%) had a Cesarean delivery. AoP was narrower in the Cesarean-delivery group at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva, whereas no differences in levator hiatal APD were found between the two groups. We found a negative correlation between levator hiatal APD at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva and the duration of the second stage of labor. There was a positive correlation between AoP and levator hiatal APD on maximum Valsalva maneuver after visual feedback (r = 0.15, P = 0.01). Women with levator ani muscle contraction on Valsalva maneuver (i.e. coactivation), both pre and post visual feedback, had a narrower AoP at rest and on maximum Valsalva. After visual feedback, women with levator ani muscle coactivation had a longer second stage of labor than did those without (80.8 ± 61.4 min vs 62.9 ± 43.4 min (P = 0.04)).

CONCLUSIONS

Smaller pelvic floor dimensions and levator ani muscle coactivation are associated with higher fetal head station and with a longer second stage of labor in nulliparous women at term. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Role of Vitamin D Supplements in Prevention of Hungry Bone Syndrome after Successful Parathyroidectomy for Primary Hyperparathyroidism: A Prospective Study

BACKGROUND

We postulated that the preoperative correction of vitamin D levels can significantly reduce the incidence of hunger bone syndrome among patients undergoing parathyroidectomy for primary hyperparathyroidism.

METHODS

We performed a prospective, randomized, open-label study on 102 patients with primary hyperparathyroidism and coexisting vitamin D deficiency who were scheduled to undergo parathyroidectomy. Patients were divided into the following two groups: group I which included 52 patients who did not receive preoperative vitamin D supplementation; and group II which included 50 patients who received cholecalciferol 1000-2000 IU daily or 50000 IU weekly until they achieve vitamin D levels >20 ng/mL (group IIa = 25 patients) or vitamin D levels >30 ng/mL (group IIb = 25 patients).

RESULTS

The incidence of hunger bone syndrome in group IIb was lower than group I and group IIa (8% versus 16% versus 23%, respectively); however, this difference did not reach the level of statistical significance (p = 0.22). Patients with hunger bone syndrome were significantly younger and had higher serum phosphorus, alkaline phosphatase, magnesium, and bone mineral density at baseline than patients without hunger bone syndrome. On the other hand, patients with hunger bone syndrome had significantly lower 25-hydroxyvitamin D at baseline than patients without hunger bone syndrome (p = 0.001). The ROC curve showed that the baseline level of serum 25-hydroxyvitamin D was not an independent discriminator of hunger bone syndrome (area under curve = 0.21 (95% CI: 0.06-0.34); p = 0.011).

CONCLUSION

Preoperative course of vitamin D supplements has no preventive role on the postoperative incidence of hunger bone syndrome among patients with primary hyperparathyroidism and coexisting vitamin D deficiency undergoing parathyroidectomy.

Descent of fetal head during active pushing: secondary analysis of prospective cohort study investigating ultrasound examination before operative vaginal delivery

OBJECTIVES

To investigate if descent of the fetal head during active pushing is associated with duration of operative vaginal delivery, mode of delivery and neonatal outcome in nulliparous women with prolonged second stage of labor.

METHODS

This was a prospective cohort study of nulliparous women with prolonged second stage of labor, conducted between November 2013 and July 2016 in five European countries. Fetal head descent was measured using transperineal ultrasound. Head-perineum distance (HPD) was measured between contractions and on maximum contraction during active pushing, and the difference between these values (ΔHPD) was calculated. The main outcome was duration of operative vaginal delivery, estimated using survival analysis to calculate hazard ratios (HRs) for vaginal delivery, with values > 1 indicating a shorter duration. HR was adjusted for prepregnancy body mass index, maternal age, induction of labor, augmentation with oxytocin and use of epidural analgesia. Pregnancies were grouped according to ΔHPD quartile, and delivery mode and neonatal outcome were compared between groups.

RESULTS

The study population comprised 204 women. Duration of vacuum extraction was shorter with increasing ΔHPD. Estimated mean duration was 10.0, 9.0, 8.8 and 7.5 min in pregnancies with ΔHPD in the first to fourth quartiles, respectively, and the adjusted HR for vaginal delivery, using increasing ΔHPD as a continuous variable, was 1.04 (95% CI, 1.01-1.08). Mean ΔHPD was 7 mm (range, -10 to 37 mm). ΔHPD was either negative or ≤ 2 mm in the lowest quartile. In this group, 7/50 (14%) pregnancies were delivered by Cesarean section, compared with 8/154 (5%) of those with ΔHPD > 2 mm (P < 0.05). There was no significant association between umbilical artery pH < 7.10 or 5-min Apgar score < 7 and ΔHPD quartile.

CONCLUSION

Minimal or no fetal head descent during active pushing was associated with longer duration of operative vaginal delivery and higher frequency of Cesarean section in nulliparous women with prolonged second stage of labor. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Levator ani muscle coactivation at term is associated with longer second stage of labor in nulliparous women

OBJECTIVE

To assess the effect of levator ani muscle (LAM) coactivation at term on outcome of labor in nulliparous women.

METHODS

This was a prospective study of 284 low-risk nulliparous women with a singleton pregnancy at term recruited before the onset of labor. The anteroposterior diameter of the levator hiatus was measured in each woman on transperineal ultrasound at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver before and after visual feedback. LAM coactivation was defined as a reduction in the anteroposterior diameter of the levator hiatus on maximum Valsalva maneuver in comparison with that at rest. The association of pelvic hiatal diameter values and LAM coactivation with mode of delivery and duration of labor was assessed.

RESULTS

No significant difference was found between women who underwent Cesarean delivery and those who had a vaginal delivery with regard to the anteroposterior diameter of the levator hiatus at rest, on pelvic floor muscle contraction and on Valsalva maneuver. Longer second stage of labor was associated with shorter anteroposterior diameter of the levator hiatus on all assessments, but in particular at rest and on Valsalva both before and after visual feedback. LAM coactivation was found in 89 (31.3%) and 75 (26.4%) women before and after visual feedback, respectively. Post visual feedback, women with LAM coactivation had a significantly longer second stage of labor than did those without LAM coactivation (83 ± 63 vs 63 ± 42 min; P = 0.006). On Cox regression analysis, LAM coactivation post visual feedback was an independent predictor of longer second stage of labor (adjusted hazard ratio, 1.499 (95% CI, 1.076-2.087); P = 0.017).

CONCLUSION

LAM coactivation in nulliparous women at term is associated with a longer second stage of labor. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

How reliable is fetal occiput and spine position assessment prior to induction of labor?

OBJECTIVES

To assess the reliability of fetal occiput and spine position determination in nulliparous women prior to induction of labor (IOL), and to evaluate identification of fetal occiput and spine positions prior to IOL in the prediction of labor outcome.

METHODS

A series of 136 nulliparous women were recruited prospectively, immediately after the decision to perform IOL was made. Transabdominal ultrasound was performed to determine fetal head and spine positions. After at least 1 h, and prior to IOL, fetal occiput and spine positions were reassessed. Fetal occiput and spine positions were then compared between women who underwent vaginal delivery and those who delivered by Cesarean section.

RESULTS

On the first and second assessments, respectively, fetal occiput position was anterior in 55 (40.4%) and 62 (45.6%) women, transverse in 52 (38.2%) and 49 (36.0%) women, and posterior in 29 (21.3%) and 25 (18.4%) women, while fetal spine position was anterior in 58 (42.6%) and 52 (38.2%) women, transverse in 42 (30.9%) and 50 (36.8%) women, and posterior in 36 (26.5%) and 34 (25.0%) women. Discordance between the first and second assessments of fetal occiput position was identified in 34 (25.0%) women, whereas discordance of fetal spine position was observed in 40 (29.4%) women. The incidence of fetal occiput posterior position in women undergoing Cesarean section was comparable to that in the vaginal-delivery group (19 (18.8%) vs 6 (17.1%); P = 0.826), which was similarly the case for fetal posterior spine position (27 (26.7%) vs 7 (20%); P = 0.428). Women with fetal occiput posterior position had a longer induction-to-delivery interval in comparison to those with non-occiput posterior fetal position (1786 ± 805 vs 1347 ± 784 min; P = 0.013).

CONCLUSIONS

Fetal occiput and spine positions are dynamic in a considerable proportion of women undergoing IOL, and their assessment does not seem to correlate with mode of delivery. Occiput and spine position assessment in women prior to IOL is unlikely to be clinically useful. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Medical-grade polycaprolactone scaffolds made by melt electrospinning writing for oral bone regeneration - a pilot study in vitro

BACKGROUND

The spectrum of indications for the use of membranes and scaffolds in the field of oral and maxillofacial surgery includes, amongst others, guided bone regeneration (GBR). Currently available membrane systems face certain disadvantages such as difficult clinical handling, inconsistent degradation, undirected cell growth and a lack of stability that often complicate their application. Therefore, new membranes which can overcome these issues are of great interest in this field.

METHODS

In this pilot study, we investigated polycaprolactone (PCL) scaffolds intended to enhance oral wound healing by means of melt electrospinning writing (MEW), which allowed for three-dimensional (3D) printing of micron scale fibers and very exact fiber placement. A singular set of box-shaped scaffolds of different sizes consisting of medical-grade PCL was examined and the scaffolds' morphology was evaluated via scanning electron microscopy (SEM). Each prototype sample with box sizes of 225 μm, 300 μm, 375 μm, 450 μm and 500 μm was assessed for cytotoxicity and cell growth by seeding each scaffold with human osteoblast-like cell line MG63.

RESULTS

All scaffolds demonstrated good cytocompatibility according to cell viability, protein concentration, and cell number. SEM analysis revealed an exact fiber placement of the MEW scaffolds and the growth of viable MG63 cells on them. For the examined box-shaped scaffolds with pore sizes between 225 μm and 500 μm, a preferred box size for initial osteoblast attachment could not be found.

CONCLUSIONS

These well-defined 3D scaffolds consisting of medical-grade materials optimized for cell attachment and cell growth hold the key to a promising new approach in GBR in oral and maxillofacial surgery.

Fundal pressure in second stage of labor (Kristeller maneuver) is associated with increased risk of levator ani muscle avulsion

OBJECTIVE

To investigate the association between application of fundal pressure during the second stage of labor (Kristeller maneuver) and the risk of levator ani muscle (LAM) injury.

METHODS

This was a prospective case-control study of women recruited immediately after their first vaginal delivery in our university hospital between March 2014 and September 2016. Women who underwent the Kristeller maneuver were recruited as cases. For each case, a control (no Kristeller) was recruited matched for body mass index, use of epidural analgesia, duration of second stage of labor and birth weight. All women were invited to undergo four-dimensional (4D) transperineal ultrasound (TPU) 3-6 months postpartum. The main outcome measure was the presence of LAM avulsion on 4D-TPU. TPU results were compared between cases and controls. Multivariate logistic regression analysis was performed to identify independent risk factors for LAM avulsion.

RESULTS

During the study period, 134 women in the Kristeller maneuver group and 128 women in the control group underwent TPU assessment. Women who underwent the Kristeller maneuver had a higher prevalence of LAM avulsion than did controls (38/134 (28.4%) vs 18/128 (14.1%); P = 0.005). In addition, women in the Kristeller-maneuver group had a larger hiatal area on maximum Valsalva maneuver and a greater increase in hiatal area from rest to maximum Valsalva. On multivariate logistic regression analysis, use of the Kristeller maneuver was the only independent factor associated with LAM avulsion (odds ratio, 2.5 (95% CI, 1.29-4.51)).

CONCLUSION

The Kristeller maneuver is associated with an increased risk of LAM avulsion when applied in women during their first vaginal delivery. This should be taken into account when deciding to use fundal pressure to accelerate the second stage of labor and when counseling women following childbirth. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Endoscopic Assisted Retrosigmoid Approach for Cerebellopontine Angle Epidermoid Tumor

This case is a 20-year-old male, who presented with 1 month of right facial weakness (HB4) and complaints of ipsilateral eye dryness. He was initially treated for Bell's palsy with steroids and antiviral agents, but subsequently developed diplopia with right lateral gaze and underwent an MRI (magnetic resonance imaging). MRI demonstrated a 4.5 cm irregular lesion in the right cerebellopontine angle consistent with an epidermoid cyst. Because the tumor had grown with the development of the central nervous system, it has extended into different compartments, including the tentorial incisura and pineal region. A predefined surgical corridor created by the tumor facilitated access to the majority of the tumor through a retrosigmoid approach. Angled endoscopes (30-degree up and down) provided further visualization of tumor away from the line of sight of the microscope, thus allowing for gross total resection of the lesion. This video also demonstrates a sharp dissection technique necessary for safe removal of adherent tumor from critical neurovascular structures, including the basilar artery and several cranial nerves. The ipsilateral auditory evoked responses (ABRs) showed slight improvement from baseline toward the end of the case. A gross total resection was achieved, as shown by the MRI. The patient remained at his baseline cranial nerve (CN) V, VII, and VIII deficits during the immediate postoperative period.

The link to the video can be found at: https://youtu.be/vCq5juJh8hk.

Presigmoid Approach to Dumbbell Trigeminal Schwannoma

This case is a 15-year-old male, presenting with headaches, right face, and arm numbness, and ataxia. MRI (magnetic resonance imaging) revealed a large right sided dumbbell shaped lesion, extending into the middle and posterior fossa with compression of the brainstem consistent with a trigeminal schwannoma. Treatment options here would be a retrosigmoid suprameatal approach or a lateral presigmoid approach. Given the tumor extension into multiple compartments, a presigmoid craniotomy, combining a middle fossa approach with anterior petrosectomy, and retrolabyrinthine approach with posterior petrosectomy were used to maximize the direct access corridor for resection. The petrous apex was already expanded and remodeled by the tumor. Nerve fascicles preservation technique is paramount to the functional preservation of the trigeminal nerve. The extent of resection should be weighed against the anatomical functional integrity of the nerve. Near total resection is considered if that means more nerve preservation. Postoperatively, the patient had a slight (House–Brackman grade II) facial droop, which resolved over days and developed right trigeminal hypesthesia at several weeks. This case is presented to demonstrate a combined petrosectomy technique for resection of lesions extending into both the middle and posterior cranial fossa with near total resection and trigeminal nerve preservation.

The link to the video can be found at: https://youtu.be/kA9GyFhL1dg.

Pelvic floor muscle assessment on three- and four-dimensional transperineal ultrasound in women with ovarian endometriosis with or without retroperitoneal infiltration: a step towards complete functional assessment

OBJECTIVES

Previous studies comparing women with deep infiltrating endometriosis (DIE) and healthy controls have underlined an association between pelvic floor muscle (PFM) hypertonic dysfunction and deep lesions. The aim of this study was to compare the morphometry of PFM in women affected by ovarian endometriosis with DIE vs those without DIE in order to assess the impact of retroperitoneal infiltration by the disease on PFM function.

METHODS

This was a prospective study conducted between March 2015 and December 2016 on symptomatic women with a clinical and sonographic diagnosis of ovarian endometriosis with or without DIE, scheduled for laparoscopic surgery. We excluded patients with current or previous pregnancy, previous surgery for deep endometriosis, other causes of chronic pelvic pain or congenital or acquired abnormalities of pelvic floor anatomy. Three- and four-dimensional transperineal ultrasound was performed to evaluate PFM morphometry and assess levator hiatal area (LHA) and diameters at rest, during PFM contraction and during Valsalva maneuver. All volumes were analyzed offline by an investigator blinded to the clinical data.

RESULTS

One hundred and fourteen patients with ovarian endometriosis were enrolled in the study, 75 with DIE and 39 without DIE. The diagnosis of endometriosis was confirmed by histological examination in all patients. Compared with women without DIE, women with DIE showed a smaller LHA at rest, during contraction and during Valsalva maneuver (P = 0.03, P = 0.03 and P = 0.02, respectively) and a smaller reduction in LHA during PFM contraction (P = 0.04).

CONCLUSIONS

Women with ovarian endometriosis who were affected by DIE showed smaller hiatal dimensions than did women without DIE. Considering that PFM dysfunction in patients with DIE could cause pain symptoms and pelvic organ dysfunction, transperineal ultrasound could allow a more complete functional assessment and tailored therapy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

ISUOG Practice Guidelines: intrapartum ultrasound

The purpose of these Guidelines is to review the published techniques of ultrasound in labor and their practical applications, to summarize the level of evidence regarding the use of ultrasound in labor and to provide guidance to practitioners on when ultrasound in labor is clinically indicated and how the sonographic findings may affect labor management. We do not imply or suggest that ultrasound in labor is a necessary standard of care.

Pelvic floor muscle dysfunction on 3D/4D transperineal ultrasound in patients with deep infiltrating endometriosis: a pilot study

OBJECTIVE

Pelvic floor muscle (PFM) dysfunction seems to play an important role in the pathophysiology of pelvic pain, including that associated with deep infiltrating endometriosis (DIE). The aim of this study was to evaluate the static and dynamic morphometry of the PFM using three-dimensional (3D) and four-dimensional (4D) transperineal ultrasound in women with DIE compared with asymptomatic healthy women.

METHODS

This was a pilot, prospective study conducted at our tertiary center between March and November 2015. Fifty nulliparous women with DIE (study group) and 35 nulliparous asymptomatic healthy women (control group) were included. 3D/4D transperineal ultrasound examination of the PFM was performed in both groups. Levator hiatal area (LHA) and anteroposterior and left-right transverse diameters were evaluated at rest, on maximum PFM contraction and on maximum Valsalva maneuver. Persistent levator ani muscle (LAM) coactivation during Valsalva maneuver was investigated.

RESULTS

Compared with the control group, women with DIE had a smaller LHA at rest (P = 0.03) and during Valsalva maneuver (P < 0.01). Furthermore, reduction in LHA during PFM contraction (P < 0.001) and enlargement in LHA during Valsalva maneuver (P = 0.01) were significantly less marked. In comparison with controls, women with DIE presented a higher frequency of LAM coactivation during Valsalva maneuver, although this difference did not reach statistical significance (P = 0.05).

CONCLUSIONS

3D and 4D transperineal ultrasound is an objective and non-invasive method for PFM morphometry and may have a role in detecting PFM dysfunction in women with DIE. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Is curved three-dimensional ultrasound reconstruction needed to assess the warped pelvic floor plane?

OBJECTIVES

Caudal distension of the female pelvic floor is common and results in perineal descent and a caudally curved levator hiatus (warping). Image reconstruction of the pelvic floor using currently available ultrasound techniques involves a linear approach (flat-plane reconstruction). We aimed to evaluate the feasibility, reproducibility and potential usefulness of a new three-dimensional (3D) technique capable of reconstructing a curved plane of the levator hiatus.

METHODS

Primiparous women were recruited to undergo a 3D/four-dimensional transperineal ultrasound examination 3-6 months after delivery. Levator ani muscle warping was evaluated on Valsalva maneuver by measuring the distance between the plane extending from the pubic rami to the anorectal angle and the plane of minimal hiatal dimensions on the coronal plane. Warping distance was used to reconstruct a curved plane of the levator hiatus using the curved OmniView volume contrast imaging (VCI) technique (C-OV). Intra- and interobserver reproducibility of the C-OV technique were assessed, as was intermethod agreement between the C-OV technique and the linear OmniView-VCI (L-OV) technique, for the measurement of levator hiatal area on Valsalva maneuver.

RESULTS

Measurement of the levator hiatal area using C-OV was feasible in all 84 women recruited. The warping distance ranged from -3.5 to 9.7 mm, confirming that the 1-2-cm slice thickness traditionally used for linear reconstruction was adequate for proper assessment of levator hiatal area in our population. C-OV showed excellent intra- and interobserver reproducibility, as well as excellent agreement with the L-OV technique for measuring levator hiatal area. No systematic difference was demonstrated in any of the reproducibility studies performed.

CONCLUSIONS

3D reconstruction of the warped levator hiatal plane is feasible and highly reproducible. In our population, reconstruction of a curved plane to correct for levator hiatal warping did not offer any benefit over the traditionally performed linear reconstruction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Pheochromocytoma: A Cause of Anemia

Patients with a Pheochromocytoma usually present with intractable hypertension, postural hypotension, headaches and palpitations, with intractable hypertension being the predominant symptom. When the tumor is located in the urinary bladder, symptoms may be induced by micturition. Herein, we report a young patient with a urinary bladder Pheochromocytoma without hypertension or symptoms induced by micturition. Instead, she presented with anemia.