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E-health interventions have become increasingly popular, including in perioperative care. The objective of this study was to evaluate the effect of perioperative e-health interventions on the postoperative course. We conducted a systematic review and searched for relevant articles in the PUBMED, EMBASE, CINAHL and COCHRANE databases. Controlled trials written in English, with participants of 18 years and older who underwent any type of surgery and which evaluated any type of e-health intervention by reporting patient-related outcome measures focusing on the period after surgery, were included. Data of all included studies were extracted and study quality was assessed by using the Downs and Black scoring system. A total of 33 articles were included, reporting on 27 unique studies. Most studies were judged as having a medium risk of bias (n = 13), 11 as a low risk of bias, and three as high risk of bias studies. Most studies included patients undergoing cardiac (n = 9) or orthopedic surgery (n = 7). All studies focused on replacing (n = 11) or complementing (n = 15) perioperative usual care with some form of care via ICT; one study evaluated both type of interventions. Interventions consisted of an educational or supportive website, telemonitoring, telerehabilitation or teleconsultation. All studies measured patient-related outcomes focusing on the physical, the mental or the general component of recovery. 11 studies (40.7%) reported outcome measures related to the effectiveness of the intervention in terms of health care usage and costs. 25 studies (92.6%) reported at least an equal (n = 8) or positive (n = 17) effect of the e-health intervention compared to usual care. In two studies (7.4%) a positive effect on any outcome was found in favour of the control group. Based on this systematic review we conclude that in the majority of the studies e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative care for patients who have undergone various forms of surgery. However, due to the low or moderate quality of many studies, the results should be interpreted with caution.

Transvaginal ultrasound (TVUS) is pivotal for diagnosing reproductive pathologies in individuals assigned female at birth, often serving as the primary imaging method for gynecologic evaluation. Despite recent advancements in AI-driven segmentation, its application to gynecological ultrasound still needs further attention. Our study aims to bridge this gap by training and evaluating two state-of-the-art deep learning (DL) segmentation models on TVUS data. An experienced gynecological expert manually segmented the uterus in our TVUS dataset of 124 patients with adenomyosis, comprising still images (n = 122), video screenshots (n = 472), and 3D volume screenshots (n = 452). Two popular DL segmentation models, U-Net and nnU-Net, were trained on the entire dataset, and each imaging type was trained separately. Optimization for U-Net included varying batch size, image resolution, pre-processing, and augmentation. Model performance was measured using the Dice score (DSC). U-Net and nnU-Net had good mean segmentation performances on the TVUS uterus segmentation dataset (0.75 to 0.97 DSC). We observed that training on specific imaging types (still images, video screenshots, 3D volume screenshots) tended to yield better segmentation performance than training on the complete dataset for both models. Furthermore, nnU-Net outperformed the U-Net across all imaging types. Lastly, we report the best results using the U-Net model with limited pre-processing and augmentations. TVUS datasets are well-suited for DL-based segmentation. nnU-Net training was faster and yielded higher segmentation performance; thus, it is recommended over manual U-Net tuning. We also recommend creating TVUS datasets that include only one imaging type and are as clutter-free as possible. The nnU-Net strongly benefited from being trained on 3D volume screenshots in our dataset, likely due to their lack of clutter. Further validation is needed to confirm the robustness of these models on TVUS datasets. Our code is available on https://github.com/dilaratank/UtiSeg.

Fibroids have been identified as a possible risk factor for preterm birth, however, the magnitude of this risk is unclear. Our objective was to determine the risk of total, spontaneous, and medically indicated preterm birth in women with fibroids. A literature search was performed on 9 June 2021. We selected studies reporting on preterm birth in women with and without fibroids. Fibroids had to be diagnosed by routine ultrasound before or during pregnancy. Main outcomes were total preterm birth <37, <34, <32, and <28 weeks of gestation, and spontaneous and medically indicated preterm birth. Two authors independently performed study selection, data extraction and quality assessment. We performed quality assessment with the Newcastle-Ottawa scale. Meta-analyses were presented as Odds Ratios (ORs) with 95% Confidence Intervals (95%CIs). The search yielded 2078 unique articles of which 11 were included. Meta-analysis for preterm birth <37 weeks of gestation included 256,650 singleton deliveries: 12,309 with fibroids and 244,341 without fibroids. Women with fibroids had a higher rate of preterm birth (11.6% versus 9.0%; OR 1.66, 95%CI 1.29-2.14). Fibroids were also associated with preterm birth <34 (OR 1.88, 95%CI 1.34-2.65), <32 (OR 2.03, 95%CI 1.40-2.95) and <28 (OR 2.24, 95%CI 1.45-3.47) weeks of gestation. Data on type of preterm birth was limited: one study showed a significant association of fibroids with spontaneous preterm birth and another with indicated preterm birth. The main limitations of the included studies were the lack of correction for confounders, the risk of ascertainment bias due to possible underreporting of fibroids, and the substantial heterogeneity between studies. Our results suggest fibroids are associated with an increased risk of preterm birth, with a stronger risk at earlier gestational ages. We encourage further research to clarify the association between fibroids and preterm birth by systematic myometrial assessment in pregnancy. Prospero database [CRD42020186976].

When a vagina is dysfunctional or absent, a neovagina is typically created using an intestinal or dermal graft. This causes complications and complaints from different inherent tissue properties. We recently developed an organ-specific matrix from healthy, human vaginal wall tissue by decellularization, and demonstrated native-like matrix protein composition and mechanical properties. However, the preservation of its vascular structures is unknown, but plays a crucial role for recellularization, tissue survival and graft integration during clinical applicability. Therefore, in this explorative study the vascular architecture of human native and decellularized vagina tissue were assessed and compared. Micro-computed tomography (micro-CT) was used to analyze and quantify the three-dimensional micromorphology of blood vessels within native and decellularized human tissue. The vascular density, connectivity, length and thickness was determined for 11 test volumes from three healthy transgender donors. At a 5 μm isotropic voxel size resolution, quantitative assessment demonstrated no significant changes of the vascular density upon decellularization. However, significant decellularization-induced changes were seen for vascular connectivity ( P  < 0.001), vascular thickness ( P  < 0.01) and vascular length ( P  < 0.001). Micro-CT imaging is an effective strategy for high-resolution analysis of blood vessel structures in human (vaginal) tissue, and in bio-engineered tissue constructs. Despite significant loss of small capillaries, preservation of vascular architecture in chemically decellularized tissue was confirmed for large vascular structures through intra-patient comparison with native tissue. This validates an important aspect and predictor for functionality of a human vagina-specific matrix in terms of graft survival and integration.

Introduction After incomplete healing of the uterine cesarean section scar, a niche can be observed; 24% of the women develop large niches with a residual myometrial thickness <3 mm. In these cases a laparoscopic resection is possible. The effect of this new treatment on fertility outcome is not known yet. This paper describes reproductive outcomes 2 years after a laparoscopic niche resection and compares women with or without secondary infertility at baseline. Material and methods A prospective cohort study was performed, with consecutive inclusion of women between 2011 and 2019. Women with a niche in the uterine cesarean scar, with a residual myometrial thickness of <3 mm and with a desire to become pregnant, were scheduled to undergo a laparoscopic niche resection because of one or more of the following problems (1) postmenstrual spotting; (2) midcycle intrauterine fluid accumulation diagnosed during the fertility workup or (3) difficulties with a previous embryo transfer and preferring a surgical therapy. The study is registered in the ISRCTN register (ref. no. ISRCTN02271575) on April 23, 2013. Results There were 133 (62%) women included with a desire to become pregnant, 88 with secondary infertility. In all, 83 had an ongoing pregnancy at the 2‐year follow‐up. The ongoing pregnancy rate in patients with previous fertility problems was 60.2% compared with 66.7% in patients without infertility (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.32–1.7). The OR for live births was 0.57 (95% CI 0.02–1.2). Overall, 8.3% of the pregnancies resulted in miscarriages by the 2‐year follow‐up. Conclusions The reproductive outcomes in women with and without previous fertility problems undergoing resection of a large niche are very promising and quite comparable in both groups. These results suggest, but do not prove, a beneficial effect of this therapy for these indications. The results support the design of future randomized controlled trials to evaluate the effect of niche resection vs expectant management to assess its additional value in women with or without fertility problems who desire pregnancy. Our results show positive reproductive outcomes and improved postmenstrual spotting with few complications and lend support for carrying out randomized controlled trials for fertility reasons only.

Introduction Imaging fibroid vascularity may predict fibroid growth and aid to determine most appropriate therapy. Microvascular (MV) flow imaging is relatively new and is able to detect slow flow in small vessels. Data on feasibility, reproducibility, and reliability of MV‐flow imaging in fibroids is lacking. The purpose of our study was to determine the reproducibility of MV‐flow imaging and to explore this technique for clinical practice for assessing blood flow in fibroids. Material and Methods Thirty patients with one or multiple fibroids (diameter 1.5–12.0 cm) were prospectively included. Transvaginal ultrasound scanning was performed in B‐mode, 2D MV‐Flow™, 2D and 3D power Doppler mode (HERA W10, Samsung) by two experienced gynecologists at a tertiary care clinic from February to December 2021. The primary outcome was intra‐ and interobserver agreement of the vascular index (VI) and color score (CS). The following parameters: ‘2D MV‐flow VI’, ‘3DPD VI’, ‘2D MV‐flow CS’ and ‘2DPD CS’ were measured offline in the center, pseudocapsule, and entire fibroid. Secondary offline outcomes for exploring 2D MV‐flow for clinical practice, included (1) ability to discern vascular structures, (2) assessing the degree of vascularity via CS and calculating a VI, and (3) determining penetration depth of the ultrasound signal in both power Doppler and MV‐flow imaging. Results All scans of the 30 included patients were of sufficient quality to analyze. Inter‐ and intra‐observer correlations of all studied parameters were good to excellent, both for 2D MV‐flow and 2D power Doppler (intercorrelation coefficient 0.992–0.996). Using 2D MV‐flow different vascular structures were visible in detail, in contrary to using 2D and 3D power Doppler. In significantly more fibroids central flow could be visualized using 2D MV‐flow (63%) than with 2D power Doppler (13%, p = 0.001). Finally, penetration of the ultrasound signal was deeper using 2D MV‐flow (3.92 cm) than with 2D power Doppler (2.95 cm, p = 0.001). Conclusions Using 2D MV‐flow imaging for determining vascularity is highly reproducible. It has potential added value for clinical practice as it depicts detailed vascular structures and the degree of vascularity, especially in the center of the fibroid. Microvascular flow imaging is relatively new and is able to detect slow flow in small vessels. In 30 patients, we showed good reproducibility between microvascular flow and conventional power Doppler imaging. Microvascular flow imaging is easy to use in clinical practice as it depicts detailed vascular structures and differences in tissue penetration, especially in the center of the fibroid.

Colorectal cancer is diagnosed progressively in employed patients due to screening programs and increasing retirement age. The objective of this study was to identify prognostic factors for return to work and work disability in patients with colorectal cancer. The research protocol was published at PROSPERO with registration number CRD42017049757. A systematic review of cohort and case-control studies in colorectal cancer patients above 18 years, who were employed when diagnosed, and who had a surgical resection with curative intent were included. The primary outcome was return to work or work disability. Potentially prognostic factors were included in the analysis if they were measured in at least three studies. Risk of bias was assessed according to the QUality In Prognosis Studies tool. A qualitative synthesis analysis was performed due to heterogeneity between studies. Quality of evidence was evaluated according to Grading of Recommendation Assessment, Development and Evaluation. Eight studies were included with a follow-up period of 26 up to 520 weeks. (Neo)adjuvant therapy, higher age, and more comorbidities had a significant negative influence on return to work. A previous period of unemployment, extensive surgical resection and postoperative complications significantly increased the risk of work disability. The quality of evidence for these prognostic factors was considered very low to moderate. Health care professionals need to be aware of these prognostic factors to select patients eligible for timely intensified rehabilitation in order to optimize the return to work process and prevent work disability.

Introduction A symptomatic uterine niche is a long‐term complication after a cesarean section (CS). A group of international niche experts reached consensus on a standardized definition of a disorder caused by a symptomatic niche, named cesarean scar disorder (CSDi). However, the prevalence of this disorder is unclear. The aim of this study was to assess the prevalence of CSDi in patients 3 years after a first CS. Material and Methods A secondary analysis was performed on the 3‐year follow‐up results of the 2Close study. The 2Close study was a multicenter randomized controlled trial that evaluated single‐ versus double‐layer uterine closure at CS in 32 hospitals in the Netherlands and included 2292 patients (registered in Dutch trial register: [NTR5480]). Patients, aged ≥18 years, undergoing a first CS were included. Three months after their CS, transvaginal ultrasonography was performed to evaluate the uterine scar for the presence of a niche. Three years after their CS, a digital questionnaire was sent to evaluate the primary and secondary symptoms of CSDi. For this secondary analysis, patients were excluded if they were pregnant, breastfeeding, or using hormonal contraception. The primary outcome of the study was the prevalence of CSDi. Results Of the 1648 participants who completed the 3‐year questionnaire, patients were excluded due to pregnancy or breastfeeding (n = 305), use of hormonal contraception (n = 509), missing ultrasound evaluations (n = 76), and incomplete responses (n = 88). Of the 670 patients included in this analysis, 543 (81.0%) had a uterine niche visible on ultrasound and 127 (19.0%) were without a niche. The prevalence of CSDi at 3 years following a first CS was 42.5% (285/670). Most reported symptoms were chronic pelvic pain (35.0%), postmenstrual spotting (32.8%), and abnormal vaginal discharge (23.2%). Conclusions Our study found a high prevalence of CSDi 3 years following their first CS. Symptoms were self‐reported and the exclusion criteria of pregnancy, breastfeeding, or hormonal contraception use could have introduced selection bias. Therefore, this percentage could be an overestimation of the actual prevalence. However, this high prevalence should be included in counseling patients with a scheduled CS. Three years following a first caesarean section 42.5% of all patients develop Caesarean Scar Disorder. Most reported symptoms within the Caesarean Scar Disorder are chronic pelvic pain, postmenstrual spotting and abnormal vaginal discharge. The long‐term consequences of a Caesarean Section on patients’ health should be structurally investigated.

Background With the worldwide rising obesity epidemic and the aging population, it is essential to deliver (cost-)effective care that results in enhanced societal participation among knee arthroplasty patients. The purpose of this study is to describe the development, content, and protocol of our (cost-)effectiveness study that assesses a perioperative integrated care program, including a personalized eHealth app, for knee arthroplasty patients aimed to enhance societal participation post-surgery compared to care as usual. Methods The intervention will be tested in a multicentre randomized controlled trial with eleven participating Dutch medical centers (i.e., hospitals and clinics). Working patients on the waiting-list for a total- or unicompartmental knee arthroplasty with the intention to return to work after surgery will be included. After pre-stratification on medical centre with or without eHealth as usual care, operation procedure (total- or unicompartmental knee arthroplasty) and recovery expectations regarding return to work, randomization will take place at the patient-level. A minimum of 138 patients will be included in both the intervention and control group, 276 in total. The control group will receive usual care. On top of care as usual, patients in the intervention group will receive an intervention consisting of three components: 1) a personalized eHealth intervention called ikHerstel (‘I Recover’) including an activity tracker, 2) goal setting using goal attainment scaling to improve rehabilitation and 3) a referral to a case-manager. Our main outcome is quality of life, based on patient-reported physical functioning (using PROMIS-PF). (Cost-)effectiveness will be assessed from a healthcare and societal perspective. Data collection has been started in 2020 and is expected to finish in 2024. Discussion Improving societal participation for knee arthroplasty is relevant for patients, health care providers, employers and society. This multicentre randomized controlled trial will evaluate the (cost-)effectiveness of a personalized integrated care program for knee arthroplasty patients, consisting of effective intervention components based on previous studies, compared to care as usual. Trial registration Trialsearch.who.int; reference no. NL8525, reference date version 1: 14–04-2020.