This article explores possible relationships between migraine, irritable bowel syndrome (IBS), celiac disease (CD), and gluten sensitivity. These seemingly distinct medical entities curiously share many common epidemiological, psychosocial, and pathophysiological similarities. Considerable evidence is emerging to support a concept that experiencing significant threatening adverse events creates a state of hypervigilance in the nervous system, which associates with exaggerated response to future threats and episodic attacks of migraine and IBS. While this sensitizing response is generally considered to reside in the central nervous system, it may be possible that the initiation resides in the enteric nervous system as well. What appears to link migraine, IBS, and CD is a disease model of a genetically sensitive nervous system transformed into one that is hypervigilant, and that over time can often develop disabling and pervasive disease.

Objectives

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The provision of informed consent for antenatal and intrapartum care remains a contentious issue among healthcare professionals and has been the topic of controversies in the pages of this journal. Recently, the New South Wales (NSW) Department of Health has fundamentally changed the ground rules for the provision of maternity care within the state. In this opinion piece, we try to provide guidance to clinicians to help them deal with the medicolegal environment created by this document which is likely to affect practitioners not just in NSW.

BackgroundPelvic organ prolapse (POP) is a common chronic health issue. Pessary rings are used for conservative management. To date, there is little evidence on objective anatomical findings as predictors of successful ring pessary management.AimTo determine any association between history, clinical and four‐dimensional translabial ultrasound (TLUS)/pelvic floor ultrasound examination and pessary success.Materials and MethodsFrom November 2013 to November 1015, all new patients presenting with symptomatic prolapse to a tertiary urogynaecological unit underwent an assessment including interview, clinical examination, that is, International Continence Society POPQ (pelvic organ prolapse quantification) and TLUS. Women with symptomatic prolapse were offered conservative management with a ring pessary. Those who agreed had a ring inserted that day. Successful trial of pessary use was defined as continued use for at least three months. Retrospective analysis of imaging data was performed blinded to other data. Statistical analysis was performed to assess the relationship between history, examination and imaging and pessary success.ResultsOf 525 patients seen during the inclusion period, 177 had symptomatic prolapse. One hundred and twenty‐eight were offered a pessary, 89 accepted. Five had incomplete data, leaving 84. Forty‐ Two (50%) were still using the pessary at a three‐month follow‐up. Predictors associated with failure included being pre‐menopausal (P = 0.031), a previous hysterectomy (P = 0.051), increasing genital hiatus and perineal body (Gh + Pb) (P = 0.013), posterior compartment prolapse (P = 0.027) and a larger hiatal area on Valsalva on TLUS (P = 0.049). Pre‐menopausal status (P = 0.003), increasing Gh + Pb (P = 0.011) and previous hysterectomy (P = 0.001) remained significant on multivariate analysis.ConclusionsA history of previous hysterectomy is a predictor of pessary failure as are Gh+Pb on Valsalva and premenopausal status.

Digitation is common, and all forms of digitation are associated with abnormal posterior compartment anatomy. It may not be necessary to distinguish between different forms of digitation in clinical practice.

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Short oral presentation abstractsvaginal introitus perpendicular to the anal canal and in the tranversal plane. 3D-EAUS were performed with a 360• probe (2052, Ultraview-800 BK-Medical). Three gynecologists took part in the study; the first obtained all the images, and the other two assessed off-line and blindly the 2D-TPUS images and the 3D-EAUS volumes, respectively. Length, depth and size of the defect were scored according Starck's system (3), in both 2D and 3D techniques for each patient. Correlation for each variable to compare 2D-TPUS against 3D-EAUS was carried out in external and internal sphincter (EAS and IAS) using a Coehn's kappa (k). Results: Images from 83 patients were evaluated, with mean time between delivery and ultrasound of 37 months . Correlation between 2D-TPUS and 3D-EAUS was weak for EAS (length k = 0.16, depth k = 0.21 and size k = 0.16). While it was moderate for IAS (length k = 0.34, depth k = 0.46 and size k = 0.42). Objectives: Hypertrophy of the internal anal sphincter (IAS) is frequently observed on imaging of the anal canal and is assumed to be a factor in obstructed defecation (OD). We determined IAS thickness in a large series of women with known posterior compartment anatomy to determine whether IAS thickness is an independent predictor of OD symptoms.Methods: This was a retrospective study involving women attending a tertiary urogynecological unit between 9/11 and 6/13 for symptoms of pelvic floor dysfunction. All underwent a standardized interview including symptoms of OD such as straining at stool, incomplete bowel emptying and digitation, clinical examination and 4D transperineal ultrasound (US). IAS thickness, rectocele, enterocoele and intusussception were assessed retrospectively in US volume data, blinded against other clinical data. We assessed IAS thickness by locating the thickest aspect of the IAS in the mid-sagittal plane in a volume obtained at rest, then measuring IAS thickness at 3,6,9 and 12 o'clock in the corresponding coronal plane.Results: 775 women were seen during the inclusion period. Mean age was 56 years (18-88), mean BMI was 28 (15-55). 64% had OD symptoms. On imaging, mean IAS thickness was 2.9 (1.5-6.5) mm. 14% and 52% had a significant enterocele and rectocele respectively. A rectal intusussception was seen in 6%. IAS thickness was weakly associated with OD symptoms on univariate analysis (OR 1.29 [1.03-1.62], p = 0.038) per mm thickness, but this association disappeared when controlled for anatomical abnormalities of the posterior compartment. On the other hand, IAS thickness was clearly related to age (r = 0.227, P < 0.001) and Body Mass Index (r = 0.161, P < 0.001). Conclusions: IAS thickness does not seem to be an independent predictor of symptoms of OD. It seems associated with advancing age and higher Body Mass Index. Objectives: Rising Caesarean Section (C/S) rates are commonly considered a problem. Attempts to lower the C/S rate may involve proposals to change obstetric practice. It has recently been suggested that obstetricians should tole...