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The aim of intrapartum fetal monitoring is to identify fetal hypoxia and intervene appropriately before permanent damage occurs, while concomitantly avoiding unnecessary operative deliveries. Therefore, such monitoring needs to identify fetuses whose physiological defence mechanisms are becoming compromised, so that healthcare professionals can act before an uncontrolled phase leading to injury occurs.
Modern gynaecology has witnessed a rapid evolution and a widespread application of endoscopic techniques over the past 20 years, particularly those seen in hysteroscopy. This has been made possible mainly due to technological developments relating to instrumentation and equipment, along with continuous improvements related to surgical techniques. The advances in technology and techniques, have made hysteroscopy less painful, less invasive and an outpatient procedure . Together with transvaginal ultrasound it provides the gold standard for diagnosis of uterine pathology.
Hysteroscopy enlarges the diagnostic capacity by minor surgical operative procedures like removal of IUD, biopsy or removal of polyps and minor synechiolysis.
This chapter provides a description of basic hysteroscopic procedures including simple operative procedures like second- and third-generation endometrial ablation and grade 0 to grade 1 myomectomy for small myomas.
The improvements in techniques, endoscopic instrumentation and surgical experience have completely changed the approach to uterine intracavitary pathologies, allowing the physician to achieve more reliable diagnostic and therapeutic results. The advent of these new technologies allows us today to improve advanced hysteroscopic surgery by increasing the efficacy of an operating room environment but avoiding the need for the inpatient setting for most of the procedures. It is possible to treat severe cervical stenosis or intrauterine synechiae, including Asherman’s syndrome, G2 myomas, congenital uterine malformations, adenomyosis and chronically retained products of conception in an ambulatory setting. The future looks to further the simplification of instrumentation, and establish a safer and easier delivery of energy sources.
This chapter provides a description of advanced hysteroscopic procedures and their benefits in modern gynaecological practice.
Labour is defined as a series of physiological phenomena whereby the fetus, membranes and placenta are expelled from the uterus at a period in pregnancy where extrauterine survival is possible. The onset of labour implies the occurrence of rhythmic and effective uterine contractions that lead to progressive effacement and dilation of the cervix. This process is required before the fetus can progress through the birth canal.
When the desire to have a child no longer exists and the family is completed, women and men can opt for tubal sterilization or vasectomy as a definitive form of contraception. For the female partner it offers the opportunity that she can rely on a natural hormonal cycle without the need to use a hormonal or mechanical contraceptive method. Most frequently, due to changes in family situation, couples can regret the sterilization procedure and opt for another pregnancy. Because of proven fertility, pregnancy rates after microsurgical tubal anastomosis vary between 60% and 80%. Outcomes of vasovasostomy are quite variable, with patency rates ranging from 69.2% to 97.8% and pregnancy rates ranging from 36.8% to 92.5%. These results have to be balanced against the possibilities of artificial reproductive techniques. Factors influencing this decision are age, method of tubal sterilization, desire to have only one additional child and reimbursement in health insurance cases.
Postgraduate training in obstetrics and gynaecology relies heavily on the acquisition of practical and procedural skills in a broad array. The European Board and College of Obstetrics and Gynaecology (EBCOG) have recently revised their postgraduate training curriculum according to competency-based training principles . The EBCOG curriculum contains 10 core entrustable professional activities (EPAs)  and 8 elective EPAs, in which competency levels of technical and procedural skills as well as communication skills are defined.
The interaction between cancer cells and the surrounding microenvironment is determinant for metastasis success. In this study, the ultrastructural relevance of cells in the malignant pleural effusion (MPE) of women with breast cancer history was investigated. In MPE, it is possible to observe single cells and clusters. Women whose MPE presents carcinomas in aggregates have a better prognosis when compared to cases in which metastatic single cells are found. Samples were collected via fine-needle aspiration puncture (US-FNA). Subsequent to the material preparation and ultrathin cuts, they were observed using light and transmission electron microscopy (LM/TEM). LM and TEM images served as a basis for the creation of a digital sculpture using ZBrush® software. Clusters exhibited structural stability, en route vesicles allowing exocytosis of electron-dense fibrous elements, and cytoplasmic protrusions contributing to migratory and invasive skills. Single cells presented different necrotic phenotypes and many displayed leukocyte-like characteristics. Cluster cooperative relationships seem to be related to a long-term permanence in MPE. The absence of a collaborative network presumably triggers a more aggressive behavior of single cells. Its putative fusion with leukocytes can maximize the efficiency for transendothelial migration, increasing chances of metastatic success and, unfortunately, reducing survival of women with recidivism.
To describe the incidence of seasonal respiratory viral infections (s-RVIs) before and during the coronavirus disease 2019 (COVID-19) pandemic and to compare virus-specific patient outcomes in pediatric patients.
A retrospective cross-sectional study including patient admissions to the Children’s National Hospital between October 1, 2015, and December 31, 2020.
Among 12,451 patient admissions between March 15 and December 31, 2020 (cohort 1), 8,162 (66%) were tested for severe acute respiratory coronavirus virus 2 (SARS-CoV-2), and 249 (2.0%) were positive. Among 10,986 patient admissions between April 1 and December 31, 2020 (cohort 2), 844 (8%) were tested for s-RV upon admission and 160 were positive. Thus, 1.5% of patient admissions were associated with laboratory-confirmed s-RVIs. Among the 49,901 patient admissions during a viral season between October 1, 2015, and March 31, 2020 (cohort 3), 7,539 (15%) were tested for s-RV upon admission and 4,531 were positive; thus, 9.0% of patient admissions were associated with laboratory-confirmed s-RVIs. hHRV/rENT was the most detected virus, but the detection rate decreased substantially (31% vs 18%; P < .001) during the COVID-19 pandemic. No patients had RSV, influenza, hMPV, hPIV, or hCoV detected upon admission after April 21, 2020. The 3 patient cohorts had no statistically significant difference in the percentage of ICU admissions (10.8% vs 15.0% vs 14.2%; P > .05) or death at discharge (0.8% vs 0.6% vs 0.5%; P > .05).
Compared to COVID-19, s-RVI cases were associated with a higher proportion of inpatient admissions but were similar in ICU admission and death rates in hospitalized pediatric patients. Public health interventions for preventing COVID-19 were highly effective in preventing pediatrics s-RVIs.
The cryopreservation of murine ovarian tissue and its transplantation can be a promising technique for the preservation of fertility and an alternative for the future reconstitution of scientific valuable strains of mice. Accordingly, the aim of this study was to describe the entire surgical procedure for ovariectomy and dorsal subcutaneous autotransplantation in mice, and also some data about the efficiency of this procedure. Female C57Bl/6J mice (n = 18) were anaesthetised and bilaterally ovariectomized. After surgery, ovaries were autotransplanted in small subcutaneous pouches in the dorsal region of the forelimbs. The animals were inspected daily and, 23 days after transplantation, euthanasia and recovery of ovarian tissues were performed. Postoperative recovery, oestrous cyclicity, and folliculogenesis progression were evaluated. At 23 days after transplantation, the recovery of the ovaries was feasible, all classes (primordial to antral) of follicles were observed. Additionally, satisfactory efficiency rates were obtained, with 100% of anaesthesia survival rate, survival, graft recovery, folliculogenesis progression and oestrous cyclicity. In general, this short article describes ovarian ectopic autologous transplantation as an effective technique for maintaining rodent oogenesis and endocrine ovarian function. Even more broadly, we can still assume that the application of this technique may reduce the number of breeding matrices and experimental animals in the near future.
Vision and hearing impairments are highly prevalent in adults 65 years of age and older. There is a need to understand their association with multiple health-related outcomes. We analyzed data from the Resident Assessment Instrument for Home Care (RAI-HC). Home care clients were followed for up to 5 years and categorized into seven unique cohorts based on whether or not they developed new vision and/or hearing impairments. An absolute standardized difference (stdiff) of at least 0.2 was considered statistically meaningful. Most clients (at least 60%) were female and 34.9 per cent developed a new sensory impairment. Those with a new concurrent vison and hearing impairment were more likely than those with no sensory impairments to experience a deterioration in receptive communication (stdiff = 0.68) and in cognitive performance (stdiff = 0.49). After multivariate adjustment, they had a twofold increased odds (adjusted odds ratio [OR] = 2.1; 95% confidence interval [CI]:1,87, 2.35) of deterioration in cognitive performance. Changes in sensory functioning are common and have important effects on multiple health-related outcomes.
Toll-like receptor 4 (TLR4) is best known for its role in bacteria-produced lipopolysaccharide recognition. Regarding female reproduction, TLR4 is expressed by murine cumulus cells and participates in ovulation and in cumulus–oocyte complex (COC) expansion, maternal–fetal interaction and preterm labour. Despite these facts, the role of TLR4 in ovarian physiology is not fully understood. Therefore, the aim of the present study was to investigate the effects of TLR4 genetic ablation on mice folliculogenesis and female fertility, through analysis of reproductive crosses, ovarian responsiveness and follicular quantification in TLR4−/− (n = 94) and C57BL/6 mice [wild type (WT), n = 102]. TLR4-deficient pairs showed a reduced number of pups per litter (P = 0.037) compared with WT. TLR4−/− mice presented more primordial, primary, secondary and antral follicles (P < 0.001), however there was no difference in estrous cyclicity (P > 0.05). A lower (P = 0.006) number of COC was recovered from TLR4−/− mice oviducts after superovulation, and in heterozygous pairs, TLR4−/− females also showed a reduction in the pregnancy rate and in the number of fetuses per uterus (P = 0.007) when compared with WT. Altogether, these data suggest that TLR4 plays a role in the regulation of murine folliculogenesis and in determining ovarian endowment. TLR4 deficiency may affect ovulation and pregnancy rates, potentially decreasing fertility, therefore the potential side effects of its blockade have to be carefully investigated.
Barrier islands are sedimentary bodies susceptible to changes in sediment supply, dominant physical processes, and sea level. The aim of this work was to study the sedimentary processes that established Marambaia Barrier Island (SE Brazil) as an elongated sandy body that created Sepetiba Bay. For this purpose, barrier and back-barrier bay environments were analyzed using high-resolution satellite imagery, geophysical and topographic surveys, surface sediment samples and short cores, and radiocarbon and optically stimulated luminescence (OSL) dating techniques. Seven morpho-sedimentary domains were identified: coastal beach ridges, overland flow features, inter-ridge paleo lagoon, bayside beach ridges, marshlands, dune field and tidal wetlands. The results show that Marambaia Barrier Island evolved throughout the Holocene, first under normal regression conditions during sea-level rise, and then by forced regression as sea level lowered to its present position. Concurrent processes related to longshore drift, onshore transport, reworked barrier deposits, eolian transport, bay circulation, and pedogenesis influenced its morpho-sedimentary evolution. Morphological features such as truncated beach ridges, flying spits, and filled channels attest to the occurrence of alternating periods of erosion and accretion, evincing how the morphology of barrier island systems preserves an important archive of environmental changes.
Threatened preterm labor (TPL) is a traumatic event during pregnancy that involves a threat to the physical integrity of the upcoming baby. Despite biomarkers would be the strongest delivery date predictors, an assessment of chronic and acute stress response to TPL diagnosis may improve this prediction.
The objective is to predict delivery date in women with TPL based on their response to this diagnosis and chronic stressors, along with relevant obstetric variables.
A prospective cohort study was conducted with a sample was formed by 157 pregnant women with TPL diagnosis between 24 and 31 weeks. Determination of salivary cortisol, α-amylase levels, along with anxiety and depression symptoms were measured to estimate stress response to TPL. Cumulative life stressors as traumas, social and familiar functioning were also registered. To examine the effect of the possible predictor variables of delivery date, linear regression models were used.
A correlation was found between the variables of response to chronic stress and between the variables of psychological response to stress. The main predictors of preterm delivery were low family adaptation, higher BMI, higher cortisol levels, and the week of diagnosis of TPL (<29 weeks of gestation).
The best predictor of delivery date was the combination of the stress response to the diagnosis of TPL measured by cortisol in saliva, cumulative life stressors (mainly family adaptation) and obstetric factors (week TPL and BMI). Through psychosocial therapeutic intervention programs, it is possible to influence this modifiable predictive factors of preterm birth in symptomatic women.
Published evidence describes the appearance of manic episodes in patients who suffer localized brain lesions with no prior psychiatric history.
A case report is presented alongside a review of the relevant literature regarding the relationship between Bipolar disorder and strokes.
We present the case of a 54-year-old man who, after suffering a pontine hemorrhage, developed a depressive mood for which he was treated with Sertraline 50 mg. The following month the patient developed hypomanic mood, disinhibition, insomnia and megalomaniac ideation. He was treated with Risperidone 2 mg and the antidepressant was withdrawn. The symptomology disappeared shortly after but a few months later he developed a major depressive disorder (inhibition, ideas of ruin and guilt, low mood, decreased intake and daily activities…). He was treated again with antidepressants (Citalopram 30mg) and lithium was introduced in the absence of a total response.
Mania secondary to brain lesions has been observed in multiple studies, where an association is made mainly with lesions at the frontal, temporal, subcortical limbic brain areas and in lesions causing hypofunctionality on the right side. Most of the cases described occurred in male patients with no prior psychiatric record and with associated vascular risk.
It is important to carry out an exhaustive medical history to be able to identify the cases of secondary mania so as not to ignore the underlying neurological condition in the approach.
We present the case of an 82-year-old patient who was treated by our liaison psychiatry unit after a suicide attempt through prescription-drug overdose. The patient had been diagnosed with Parkinson’s disease (PD) ten years prior to his admittance and was being treated with carbidopa/levodopa and non-ergot dopamine agonists.
Impulse control disorders and depression are the most prevalent neuropsychiatric manifestation of PD. According to several sources, this symptomatology is underdiagnosed and undertreated, causing helplessness and distress to patients and their caregivers. Likewise, the accumulated evidence suggests that certain drugs can contribute to the appearance of the aforementioned symptoms.
A case report is presented alongside a review of the relevant literature regarding the neuropsychiatric manifestations in the context of PD and the diagnosis and treatment of these symptoms.
During his treatment, ropinirole was removed while quetiapine was progressively administered (up to 150mg/day). Carbidopa/levodopa regime was increased causing visual hallucinations and delusional jealousy. A careful balance between antiparkinsonian and antipsychotic medication needed to be achieved before discharge.
Neuropsychiatric manifestations in the context of PD are more prevalent than what was thought in the past. Certain medications, particularly non-ergot dopamine agonists could potentially contribute to the onset of these symptoms. Moreover, these manifestations can be underdiagnosed due to the stigma or social burden imposed upon family and / or caregivers. It is important that recent advances in the understanding of non-motor symptomatology of PD could permeate clinical practice to achieve an adequate identification and treatment of these symptoms.
Bipolar disorder (BD) is a severe and chronic illness characterized by episodic changes in mood. The average onset of BD symptoms is estimated between 18 and 22 years. However, many adults retrospectively report symptoms onset in childhood or adolescence. Over the last decades, pediatric bipolar disease (PBD) has been the focus of increased attention mainly due to controversies surrounding its prevalence, diagnosis and treatment in the pediatric population.
To analyze pediatric hospitalizations related to BD held in mainland Portuguese public hospitals between 2000 and 2015.
This retrospective observational study analyzed all pediatric (<18 years old) inpatient episodes from 2000 to 2015 with a primary BD diagnosis, using an anonymized administrative database including all hospitalization from mainland Portuguese public hospitals. ICD-9-CM codes 296.x were used (excluding codes 296.2x; .3x and .9x). Age at admission, admission type and date, sex, charges and length of stay (LoS) were analyzed.
A total of 348 hospitalizations were analyzed from 258 patients. Patients were mainly young girls (60.6%), with a mean age of 15.24±1.87 years. The majority of the admissions were urgent (81.0%), and the median LoS was 14 days (IQR: 7; 24). Mean hospitalization charges were 3503.1€ with a total sum of 1.2M€ for all the episodes.
PBD hospitalizations occur predominantly in female patients during adolescence. The majority of them are urgent admissions. Descriptive studies will help to describe and characterize sociodemographic and clinical trends in PBD in order to better prevent acute hospitalizations with inevitable social and economic implications.
Multiple neuroendocrine disorders can present themselves through diverse psychiatric symptoms. In the case of hypothyroidism it can manifest itself through mood disorders that will require a comprehensive differential diagnosis.
We present a case report and a review of the relevant literature about the relation between mood disorders and hypothyroidism.
We present the case of a 56-year-old man with no prior psychiatric record who concurring with a grieving process, developed a depressed mood, fatigue, decreased daily activity, and home isolation for months of evolution. He was diagnosed of hypothyroidism and treated with levotiroxine. It was necessary to boost hormonal treatment with antidepressant drugs due to the persistence of the symptoms after the resolution of the hormonal deficit.
The relationship of depression in patients with overt hypothyroidism is widely recognized. Common alterations to both disorders that could make their diagnosis difficult have been observed: existence of psychomotor slowing, attentional and executive disturbance, anxiety, asthenia, weight gain, depressed mood or bradypsychia among others. In the case of subclinical hypothyroidism, certain neuropsychiatric disorders have been linked without having conclusive evidence.
An early screening of thyroid function at the onset of psychiatric symptoms in individuals without prior psychiatric record is essential in the provision of adequate treatment. Clinical improvement has been seen with hormone replacement therapy alone. However, in up to 10% of patients it becomes insufficient, being necessary to complete it with antidepressant drugs for the complete resolution of the condition.
Maternal age and related factors, such as social vulnerability, are associated with neurodevelopmental and behavioral disorders in offspring.
To examine the influence of maternal age and its related factors on the appearance of autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), alterations in executive functions and behavioral syndromes of the offspring.
A prospective study was conducted, consisting of 131 healthy pregnant women aged 20 to 41 years, recruited at 38 weeks’ gestation. Their offspring were followed up to 2 years after birth, when psychopatology was assessed. Maternal age and possible related factors were considered predictors. Bayesian ordinal regression models were performed for each outcome variable.
Symptoms of ASD in children were associated with an older maternal age (OR = 0.188; 95% CI[1.062, 1.401]) and a lower educational level of the parents (OR = -0.879; 95% CI[0.202, 0.832]), meanwhile poor social support predicted most ADHD symptoms OR = -0.086; 95% CI[0.838, 1]) and executive dysfunctions OR = -0.661; 95% CI[0.313, 0.845]. Lower parental education predicted both externalizing and internalizing behavior.
Maternal age-related factors were the main predictors of neurodevelopmental disorders in offspring, rather than maternal age. The performance of prenatal interventions in pregnant women with advanced age and anxious depressive symptoms or adverse social situation, is crucial to reduce the risk of neurodevelopmental disorders in the offspring. Likewise, being able to carry out an early detection of childhood psychopathology would allow the implementation of resources that improve their long-term prognosis.
We present the case of a 34-year-old female patient with no prior psychiatric record who was treated in our outpatient department due to persecutory delusions of recent onset. The patient had a history of refractory temporal epilepsy since adolescence and underwent a temporal lobe resection 4 month prior to the appearance of her symptoms.
Temporal lobe resection is a well-established technique to treat refractory temporal lobe epilepsy in which psychotic symptoms are an infrequent complication; the most frequent being cognitive sequelae, visual field defects and depression. According to several sources, this symptomatology may be underdiagnosed and undereportend and there have been a number of case reports and series of cases which describe the aforementioned entity.
A case report is presented alongside a review of the relevant literature regarding cases of secondary psychosis after brain surgery.
During her treatment we administered olanzapine up to doses of 7.5mg per day because of the risk of reducing the convulsive threshold. We observed a marked improvement and the disappearance of the delusions. The dose of olanzapine has been maintained for a year with no important side-effects and without a relapse in symptoms.
Psychotic symptoms as a complication of temporal lobe resection may be more frequent than what was thought in the past. It is important to study this phenomenon more in-depth because the symptoms may remain undetected and present worse outcomes given that there are effective treatments which could ameliorate the condition.