INTRODUCTION:Endometriosis is an under-researched disease, with Aotearoa-specific data severely lacking. Current estimates of parameters such as rates of endometriosis diagnosis, indication for surgery and sites of disease are based on international data. There is currently no published data on endometriosis surgeries in Aotearoa New Zealand. AIMS:We aimed to describe the laparoscopic surgeries conducted for suspected endometriosis at Te Whatu Ora - Capital and Coast, including the prevalence of endometriosis in this cohort, indication for surgery, symptoms experienced, endometriosis stage and sites involved, number of repeat laparoscopies, and prevalence of endometriosis at repeat surgery. MATERIALS AND METHODS:To conduct this retrospective cross-sectional study, data were extracted from Te Whatu Ora - Capital and Coast systems to identify all records indicating surgery for suspected endometriosis during 2018 and 2019. Variables investigated included age, ethnicity, endometriosis diagnosis (International Classification of Diseases-10 Clinical Modification coding), stage of endometriosis, histological report and endometriosis symptoms (pain and/or fertility). RESULTS:There were 436 surgeries for suspected endometriosis performed during 2018 and 2019, and endometriosis was diagnosed in 68.3% of these surgeries. Pacific and Asian people were under-represented in the study cohort compared to the demographics of the hospital catchment area (Pacific: 3.0% vs 8.4%, Asian: 9.9% vs 12.9%). The most common indication for surgery was pain. There were 76 surgeries performed for suspected recurrence of endometriosis, and endometriosis was identified in 55.6% of these. CONCLUSIONS:Endometriosis surgeries in this hospital in Aotearoa show similar presentations and surgical findings to international data. Our findings highlight areas requiring more research in an Aotearoa-specific context.

Endometriosis is a common gynaecological condition, with a long diagnostic delay. Surgery is required to confirm a diagnosis, highlighting the need for a non-invasive biomarker. Extracellular vesicles (EVs) may have a role in endometriosis pathogenesis, yet there is limited EV biomarker literature available. This study aimed to investigate the feasibility of isolating cervico-vaginal fluid EVs sampled using cervical brushes and vaginal swabs and to compare these methods. After providing informed consent, patients undergoing surgery for suspected endometriosis had cervical brush and vaginal swab samples collected under general anaesthetic. Isolated EVs were characterised through negative stain transmission electron microscopy (TEM), Western blotting (TSG101, CD63, Calnexin, ApoB, Albumin), tunable resistive pulse sensing (TRPS), microBCA assays and RT-qPCR of miRNAs. PCR was performed on samples prior to EV isolation to assess bacteria present in samples. Cervical brush and vaginal swab EVs were intact vesicles with limited co-isolated contaminants. Cervical brushes had higher concentrations of particles compared to match vaginal swabs, although both samples had low concentrations. Protein and miRNA yield were similar between matched samples. PCR demonstrated only a small amount DNA within samples was bacterial (>0.5%). Cervico-vaginal fluids EVs were successfully isolated from cervical brushes and vaginal swabs, demonstrating a new method of sampling reproductive EVs. EV yield from both sample types was low. Similar protein and miRNA levels suggest either sampling method may be suitable for biomarker studies.

AIM Despite increasing interest in reduction of surgical site infection (SSI) after caesarean section, there is limited evidence around optimal dressing choice. We report the experience of a secondary hospital in regional New Zealand changing from a basic contact dressing to a hydrocolloid dressing over a three-month period, reporting SSI rates, midwifery and nursing experience, and cost. METHOD A retrospective cohort study of hydrocolloid dressings for caesarean sections over three months, compared with basic contact dressings in caesarean sections in the same period one year previously. We report wound swabs with significant growth; results from a survey sent to midwifery and nursing staff; and cost per dressing, as well as the number of dressing changes before discharge. RESULTS In the hydrocolloid group (n=94) four patients had significant growth on wound swabs (4.3%, 95% confidence interval (CI): 0-10.6%) compared with six patients in the basic contact group (n=117) (5.1%, 95% CI: 1.0-7.1%). Only 9/20 (45%) midwives reported that they liked the hydrocolloid dressings, compared with 19/21 (90%) liking the basic contact dressings, primarily due to difficulty removing the dressings. When accounting for the number of dressing changes on the ward, the cost per caesarean section was $5.11 NZD for hydrocolloid dressings, compared with $5.72 NZD for basic contact dressings. CONCLUSION Our initial experience with a change to hydrocolloid dressings showed promising results with regard to SSI rates, as well as a cost reduction. This, however, is to be balanced with dressings that are potentially more difficult to remove, resulting in reduced midwifery and nursing satisfaction.

Background: Symptom tracking for endometriosis has been validated with clinical benefits, however, there is limited evidence around the use of mobile apps for endometriosis symptom tracking. Method: We performed a survey of people with suspected or confirmed endometriosis in Aotearoa New Zealand to assess mobile app use for symptom tracking including which app is being used, how frequently symptoms are tracked, which features are most important and which features would be desired. We also explored willingness to share symptom data with clinicians and/or researchers. Results: A total of 188 survey responses were included. Mobile apps were used for symptom tracking by 83/188 (44.1%), with only 13 of 188 (6.9%) reporting they would not consider use of an app. Of current app users, 51.5% reported logging symptoms at least weekly. The most frequently desired features included tracking of specific symptoms (such as periods, pain, bowel symptoms, mental health symptoms), other tracking (such as medications and diet) and general app usability. Of those who use or would consider using an app 77.7% reported they would be comfortable sharing data with clinicians, and 76.1% reported they would be comfortable sharing anonymous data with researchers. Discussion: Almost half of participants reported using an app to track symptoms, and almost all reported they would consider use. Around three in four patients would be willing to share this data with clinicians and researchers, and therefore further focus on the utility of these apps may benefit patients directly, their relationship with healthcare providers and be utilised for further endometriosis research.

Endometriosis is a chronic, inflammatory gynaecological disease that can have severe negative impacts on quality of life and fertility, placing burden on patients and the healthcare system. Due to the heterogeneous nature of endometriosis, and the lack of correlation between symptom and surgical disease severity, diagnosis and treatment remain a significant clinical challenge. Extracellular vesicles (EVs) are biologically active particles containing molecular cargo involved in intercellular communication, that can be exploited for diagnostic and therapeutic purposes. We systematically reviewed studies exploring EVs and their role in endometriosis, specifically addressing diagnostic and therapeutic potential and current understanding of pathophysiology. Five databases (Pubmed, Embase, Medline, Web of Science, Google Scholar) were searched for keywords ‘endometriosis’ and either ‘extracellular vesicles’ or ‘exosomes’. There were 28 studies included in the review. Endometrium derived EVs contribute to the development of endometriosis. EVs derived from endometriosis lesions contribute to angiogenesis, immunomodulation and fibrosis. Such EVs can be detected in blood, with early data demonstrating utility in diagnosis and recurrence detection. EV isolation techniques varied between studies and only eight of twenty-eight studies fully characterised EVs according to current recommended standards. Reporting/type of endometriosis was limited across studies. Varied patient population, type of sample and isolation techniques created bias and difficulty in comparing studies. EVs hold promise for improving care for symptomatic patients who have never had surgery, as well as those with recurrent symptoms after previous surgery. We encourage further EV research in endometriosis with the inclusion of rigorous reporting of both the patient population and technical methodology used, with the ultimate goal of achieving clinical utility for diagnosis, prognosis and eventually treatment.

AIMS:To evaluate the approach to diagnosis and management of caesarean scar pregnancy (CSP) at a regional New Zealand hospital. METHODS:A retrospective case series of ten patients between June 2015 and May 2020. The data review included demographic information, ultrasound findings, human chorionic gonadotropin (HCG) levels, primary and subsequent treatment, outcomes and complications. RESULTS:Nine women were diagnosed with CSP at a gestational age between four and ten weeks. One of these women was treated twice for two separate CSP within the study period. Treatment varied according to clinical presentation, HCG levels, gestational age, ultrasound findings and patient preference. Two thirds of women were successfully treated with primary management, with one third requiring multiple treatment modalities. We report one severe life-threatening haemorrhage and three cases resulting in hysterectomy. We also show a disproportionate number of Māori women presenting with CSP. CONCLUSION:We present a series of ten cases of CSP and demonstrate similar challenges in regional New Zealand to those reported elsewhere. Management is heterogeneous with little guidance from the literature, and primary management was successful in seven out of ten cases. We report a disproportionately high number of cases in Māori women. Our results would support the development of a national register for caesarean scar pregnancy to improve diagnosis and management across New Zealand.

Background Cervical smear cytology and colposcopic biopsy histology are prone to error at both collection and interpretation stages, leading to a large number of discordant cases. Aims Investigation of five‐year outcomes for women who have cervical cytology that is discordant and higher grade than histology results. Materials and Methods A retrospective cohort study was carried out for 111 women with cervical cytology discordant and higher grade than histology, after cytopathological review, over a three‐year period. Five‐year follow‐up data were reviewed to identify the highest level of pathology seen within five years from the discordance. Results Women with atypical squamous cells with possible high‐grade change (ASC‐H) cytology and negative biopsy ( n = 28) had a 46% chance of high‐grade histological disease within 5 years; with cervical intraepithelial neoplasia grade 1 (CIN1) histology ( n = 20), this was reduced to 30%. With high‐grade cytology and negative histology ( n = 23), 48% had high‐grade disease within five years, including one case of invasive disease; with CIN1 histology 50% had high‐grade disease within five years. Conclusions This study demonstrates a 30–50% chance of high‐grade disease within five years, in the setting of ASC‐H or high‐grade cytology with a negative or low‐grade colposcopic biopsy. This highlights that in the setting of cytology and histology discordance, at least one of the tests indicating high‐grade pathology warrants the need for treatment or close ongoing surveillance.

Journal of Wound CareVol. 30, No. 7 Guest EditorialFree AccessCaesarean section dressings: what to put on and when to take it offSimon M ScheckSimon M ScheckUniversity of Otago, Department of Obstetrics, Gynaecology and Women's Health, New Zealand; Palmerston North Hospital, Department of Obstetrics and Gynaecology, Mid Central District Health Board, New ZealandSearch for more papers by this authorSimon M ScheckPublished Online:14 Jul 2021https://doi.org/10.12968/jowc.2021.30.7.514AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail Simon M ScheckSurgical wound complications include surgical site infections (SSI) and other non-infective complications, such as dehiscence.1 Such complications following caesarean section are common, with the major risk factor being obesity, as well as a range of other factors, for example, emergency procedures or gestational diabetes.2 Evidence-based care bundles to prevent SSI and other wound complications after caesarean section are common and have been shown to be beneficial.3 Despite increasing literature around interventions to reduce rates of surgical wound complications, there is limited evidence on the optimal dressing and the timing of dressing removal after caesarean section.Which dressing to use?The options available for wound dressings are:4Basic wound contact (pad or gauze covered by adhesive film)Film (permeable to water vapour but not water or microorganisms)Hydrocolloid (occlusive dressings that absorb fluid)Negative pressure.Hydrocolloid dressings contain absorptive compounds (typically plant-based products such as carboxymethylcellulose or pectin), forming a barrier to water, oxygen and bacteria, as well as forming an acidic environment under the dressing which has antibacterial properties. They are reportedly more comfortable and adherent in high friction areas, and are transparent, allowing direct visualisation of the wound.5A Cochrane review published in 2016 reported that the risk of SSI was reduced with hydrocolloid compared with basic wound contact dressings (risk ratio: 0.57), but that no conclusions should be drawn as the evidence was of ‘very low’ quality.6With regards to caesarean sections specifically, a prospective UK study of 2382 women (after introduction of a wound care bundle which reduced infection rates by 3.3%) demonstrated a 1.3% absolute reduction in SSI rates with the introduction of hydrofibre and hydrocolloid dressings.7The use of negative pressure dressings for women with obesity having caesarean section is contentious, and two systematic reviews published in high impact journals within a year of each other (largely analysing the same studies) drew different conclusions due to slightly different definitions as discussed by Barbosa et al., highlighting the uncertainty in the evidence.8,9,10The benefit of negative pressure dressings is likely related to improved dressing integrity, especially in the setting of a sub-panniculus incision, as well as increased absorption of wound exudate. Both of these properties are also achieved (to a lesser extent) by hydrocolloid dressings;5 however, the cost of hydrocolloid dressings is significantly cheaper than negative pressure dressings, and typically similar to basic contact dressings (hydrocolloid dressings may be cheaper than frequently used advanced basic contact dressings).When to remove the dressingThe optimal timing of dressing removal after caesarean section is unclear, with conflicting evidence. A Cochrane review of all surgical procedures did not demonstrate any benefit to dressings remaining applied beyond 48 hours.11 With regards to caesarean sections specifically, one randomised controlled trial (RCT) of 869 women reported that women who had dressings intact for 48 hours were at significantly lower risk of SSI than those women whose dressings were removed at 24 hours (3.9% versus 9.0%, respectively; risk ratio: 0.43),12 while another RCT of 602 patients did not show a difference in SSI rate between removal at 24–30 hours versus 30–48 hours (7% versus 9.6%, respectively; odds ratio: 1.41).13 Another RCT of 320 women reported no difference in wound complications for dressing removal at six hours compared with 24 hours (13.8% versus 12.5%, respectively).14The conclusions of the authors of these studies seem to be conflicting, with some promoting delayed removal and others promoting early removal. The enhanced recovery after surgery (ERAS) protocol for caesarean section advocates for dressing removal at six hours after elective caesarean section, and did not show an increase in SSI rate with this (implemented with a range of other recommendations).15 The UK's National Institute for Health and Care Excellence (NICE) recommends removing the dressing at 24 hours after caesarean section.16 There are no studies specifically in women who are obese or other groups at high risk of SSI.Dressing choice as part of an SSI prevention bundleSSI prevention bundles seek to minimise the number of dressing changes and increase consistency with wound care practices; however, there is minimal evidence from which to draw conclusions. In addition, patient satisfaction and cost are both major influences in the choice of dressing and are rarely reported in the studies mentioned here.There is no standardised way to report patient satisfaction of dressings, and as any patient may not have experienced different dressings with which to compare, it is a significant challenge to obtain a true comparison between dressings. The cost of dressings are region and health system dependant, and therefore infrequently reported and difficult to extrapolate internationally.Ultimately the choice of dressing should be made on the basis of SSI prevention, patient preference and cost; hydrocolloid dressings would appear to score favourably in all three areas; however the evidence is very limited. If delayed removal of the dressing is intended, hydrocolloid dressings provide the added benefit of improved adherence, microbial seal and antimicrobial properties compared with basic contact dressings, as well as direct visualisation of the wound.Choice of dressing and optimal timing of dressing removal, especially in women at risk of surgical wound complications, are important factors that should be further investigated to guide practice. References 1 Sandy-Hodgetts, K. et al. International Expert Working Group Best Practice Meeting Attendees from ISWCAP ISWCAP Panel Members. https://tinyurl.com/5b6bx5vk? (accessed 29 June 2021) Google Scholar2 Scheck SM, Blackmore T, Maharaj D et al. Caesarean section wound infection surveillance: information for action. Aust New Zeal J Obstet Gynaecol 2018; 58(5):518–524. https://doi.org/10.1111/ajo.12755 Crossref, Medline, Google Scholar3 Carter EB, Temming LA, Fowler S et al. Evidence-based bundles and cesarean delivery surgical site infections. Obstet Gynecol 2017; 130(4):735–746. https://doi.org/10.1097/AOG.0000000000002249 Crossref, Medline, Google Scholar4 Walter CJ, Dumville JC, Sharp CA, Page T. Systematic review and meta-analysis of wound dressings in the prevention of surgical-site infections in surgical wounds healing by primary intention. Br J Surg 2012; 99(9):1185–1194. https://doi.org/10.1002/bjs.8812 Crossref, Medline, Google Scholar5 Vowden K, Vowden P. Wound dressings: principles and practice. Surg 2017; 35(9):489–494. https://doi.org/10.1016/j.mpsur.2017.06.005 Google Scholar6 Dumville JC, Gray TA, Walter CJ, et al. Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev 2016; 12:CD003091. https://doi.org/10.1002/14651858.CD003091.pub4 Medline, Google Scholar7 Gregson H. Reducing surgical site infection following caesarean section. Nurs Stand 2011; 25(50):35–40. https://doi.org/10.7748/ns.25.50.35.s48 Crossref, Medline, Google Scholar8 Smid MC, Dotters-Katz SK, Grace M et al. Prophylactic negative pressure wound therapy for obese women after cesarean delivery: a systematic review and meta-analysis. Obstet Gynecol 2017; 130(5):969–978. https://doi.org/10.1097/AOG.0000000000002259 Crossref, Medline, Google Scholar9 Yu L, Kronen RJ, Simon LE et al. Prophylactic negative-pressure wound therapy after cesarean is associated with reduced risk of surgical site infection: a systematic review and meta-analysis. Am J Obstet Gynecol 2018; 218(2):200–210.e1. https://doi.org/10.1016/j.ajog.2017.09.017 Crossref, Medline, Google Scholar10 Barbosa A, Pinto P, Lunet N. Apparently conflicting meta-analyses on prophylactic negative pressure wound therapy after cesarean delivery. Am J Obstet Gynecol 2018; 219(3):311–312. https://doi.org/10.1016/j.ajog.2018.04.034 Crossref, Medline, Google Scholar11 Toon CD, Lusuku C, Ramamoorthy R et al. Early versus delayed dressing removal after primary closure of clean and clean-contaminated surgical wounds. Cochrane Database Syst Rev 2015; 2015(9):CD010259. https://doi.org/10.1002/14651858.CD010259.pub3 Google Scholar12 Kilic GS, Demirdag E, Findik MF et al. Impact of timing on wound dressing removal after caesarean delivery: a multicentre, randomised controlled trial. J Obstet Gynaecol 2020; 1–5:1–5. https://doi.org/10.1080/01443615.2020.1736015 Google Scholar13 Nesrallah M, Cole P, Kiley K. The effect of timing of removal of wound dressing on surgical site infection rate after cesarean delivery. Obstet Gynecol 2017; 129(5):S148–S149. https://doi.org/10.1097/01.AOG.0000514733.47446.cf Crossref, Google Scholar14 Peleg D, Eberstark E, Warsof SL et al. Early wound dressing removal after scheduled cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol 2016; 215(3):388.e1–388.e5. https://doi.org/10.1016/j.ajog.2016.03.035 Crossref, Google Scholar15 Teigen NC et al. Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial. Am J Obstet Gynecol 2020; 222(4):372.e1–372.e10. https://doi.org/10.1016/j.ajog.2019.10.009 Crossref, Google Scholar16 National Institute for Health and Care Excellence. Caesarean section: clinical guideline [CG132]. 2012. https://www.nice.org.uk/guidance/cg132 (accessed 9 june 2021) Google Scholar FiguresReferencesRelatedDetails 2 July 2021Volume 30Issue 7ISSN (print): 0969-0700ISSN (online): 2052-2916 Metrics Downloaded 477 times History Published online 14 July 2021 Published in print 2 July 2021 Information© MA Healthcare LimitedPDF download

Background Cervical screening programs have had an important effect on the reduction of cervical cancer rates. Comprehensive programs require access to pathological review to improve the sensitivity of screening cytology and the specificity of diagnostic histology. Aims To determine the number of cases where cervical cytology or histology was amended at cytopathological review; whether amendments were ‘upgrades’ or ‘downgrades’, and how amendments aligned with follow‐up results for these patients. Materials and Methods A retrospective cohort study was performed of all patients reviewed from January 2016 to December 2017 ( n = 287 cases, from 254 patients) at colposcopy multidisciplinary meetings at Wellington Hospital, a tertiary referral hospital. Where amendments to cytology or histology were made, follow‐up results were retrieved where available (85.7% and 84.2% respectively). Results Cytology or histology was amended in 24.7% of cases. Smear cytology was amended in 16.7%. Where cytology was upgraded ( n = 9), 44% had subsequent results of equal or higher grade including one case of adenocarcinoma. Where cytology was downgraded ( n = 19), 93.8% (81.9–100%) had follow‐up studies showing equal or lower results. Cervical biopsy histology was amended in 12.2% of cases (upgraded n = 19, downgraded n = 6). Large loop excision of the transformation zone or cone biopsy histology was amended in three cases (7.9%). Conclusions Cytopathological review appears to improve the specificity of the comprehensive cervical screening program, leading to a reduction in unnecessary treatment. Additionally, a small number of cases of malignant or premalignant disease were detected.

AIM: The aim of this study was to determine the key influential factors for pregnant or recently pregnant women in deciding on influenza vaccination. METHOD: This study was conducted in a single tertiary hospital in New Zealand using an anonymous and voluntary patient survey. Ethnicity, age and stage of pregnancy along with self-reported data on factors that influenced the decision to vaccinate against influenza during pregnancy were recorded. RESULTS: We included 101 participants over the one-week study period, 76% of whom had received the influenza vaccination. The most commonly reported reason for vaccination was the desire for neonatal protection, the common reasons for not being vaccinated were not receiving information on vaccination or safety concerns. CONCLUSION: There are a variety of factors influencing women when deciding on antenatal influenza vaccination. Further studies are needed to expand on the findings of this small local study in order to be able to improve vaccination uptake through empathetic delivery of evidence-based recommendations.

AIM:To define the range and severity of cardiac disease in pregnant women in New Zealand, as well as the maternal and neonatal morbidity and mortality compared with the background obstetric population.METHODS:We retrospectively audited pregnant women with cardiac comorbidity seen by a multidisciplinary team at a tertiary referral centre consisting of midwives, cardiologists, obstetricians and anaesthetists in 2016-2017.RESULTS:Seventy-two women were referred to the multidisciplinary team. The most common referral reasons were arrhythmia (n=20, 27.8%), congenital anomalies (n=19, 26.4%) and palpitations (n=10, 13.9%). Fifty-two of these women were found to be at increased risk of morbidity or mortality. A specific delivery plan was devised for 37 of these women (69.8%). There was no serious maternal morbidity or mortality. Instrumental delivery rates were higher for women with cardiac comorbidity than the background obstetric population (19.2% vs 10.8%, p=0.049), however, neonatal admissions were not increased (11.5% compared with 16.5%).CONCLUSION:Multidisciplinary review of obstetric patients with cardiac disease provides an important service to ensure risk modification prior to conception and throughout pregnancy and the puerperium.

Endometrioid carcinoma with a prominent squamous component has the ability to mimic pilomatrixoma. One previous case is documented of cutaneous metastasis in the upper limb derived from ovarian endometrioid carcinoma mimicking pilomatrixoma. Here, we describe a case of metastasis of endometrial endometrioid carcinoma in the distal vagina, treated with radiotherapy and later resected. The histology of the lesion was thought initially to represent pilomatrixoma; this has not previously been described in the vagina, where no hair matrix cells are normally present. We hypothesise that radiotherapy may have effectively 'sterilised' the glandular component, blinding the malignant features. Further management was significantly altered by the reinterpretation of this result as metastatic disease. We emphasise that in the context of known endometrioid carcinoma, the diagnosis of pilomatrixoma should be made with caution, particularly where radiotherapy has been used.

Surgical site infection (SSI) following caesarean section is common, resulting in significant morbidity. Several factors are known to contribute to wound infection, including maternal, procedural and antibiotic factors. We sought to clarify these issues and sought opportunities to make improvements. A retrospective cohort study was performed assessing all women who underwent caesarean section in 2014 and 2015 at Wellington Hospital. Any women with culture‐positive wound samples within 30 days of surgery were identified, and clinical notes reviewed. Odds ratios (OR) were calculated for available maternal, procedural and antibiotic risk factors. Two simplified surveillance techniques were also tested for their abilities to identify significant trends. The study included 2231 women, of whom 116 (5.2%) were identified as having SSI. Maternal obesity (body mass index (BMI) ≥ 30) was associated with significant SSI risk (OR 4.1, P < 0.001). The pathogen distribution was significantly different between women with BMI < 30 and BMI ≥ 30 (P < 0.001). Increased cefazolin dose based on BMI (3 g dose for BMI ≥ 30) was associated with a significant reduction in SSI (OR 0.309, P < 0.001) and was administered in 74.1% of obese women receiving cefazolin. Māori women had an increased SSI risk (OR 2.1, P = 0.019), as did Samoan women (OR 3.0, P = 0.002). The study reinforces other studies showing that raised BMI is the single biggest risk factor for surgical site infection post‐caesarean section. Surveillance using simplified techniques appears to be adequate to identify trends. We believe that concentrating on appropriate antibiotic dosing and targeting special wound care measures will be pivotal interventions in improving outcomes in high‐risk groups.

Aims: To investigate the extent of white matter damage in children with unilateral cerebral palsy (UCP) caused by periventricular white matter lesions comparing between unilateral and bilateral lesions; and to investigate a relationship between white matter microstructure and hand function.Methods and procedures: Diffusion MRI images from 46 children with UCP and 18 children with typical development (CTD) were included. Subjects were grouped by side of hemiparesis and unilateral or bilateral lesions. A voxel-wise white matter analysis was performed to identify regions where fractional anisotropy (FA) was significantly different between UCP groups and CTD; and where FA correlated with either dominant or impaired hand function (using Jebsen Taylor Hand Function Test).Outcomes and results: Children with unilateral lesions had reduced FA in the corticospinal tract of the affected hemisphere. Children with bilateral lesions had widespread reduced FA extending into all lobes. In children with left hemiparesis, impaired hand function correlated with FA in the contralateral corticospinal tract. Dominant hand function correlated with FA in the posterior thalamic radiations as well as multiple other regions in both left and right hemiparesis groups.Conclusions and implications: Periventricular white matter lesions consist of focal and diffuse components. Focal lesions may cause direct motor fibre insult resulting in motor impairment. Diffuse white matter injury is heterogeneous, and may contribute to more global dysfunction.What this paper addsFocal white matter alterations are observed in the corticospinal tract in UCP with unilateral white matter lesionsDiffuse white matter alterations throughout all cerebral lobes are observed in UCP with bilateral white matter lesionsFractional anisotropy in the posterior thalamic radiations correlates with dominant hand function (c) 2016 Elsevier Ltd. All rights reserved.

In this work we investigate the structural connectivity of the anterior cingulate cortex (ACC) and its link with impaired executive function in children with unilateral cerebral palsy (UCP) due to periventricular white matter lesions. Fifty two children with UCP and 17 children with typical development participated in the study, and underwent diffusion and structural MRI. Five brain regions were identified for their high connectivity with the ACC using diffusion MRI fibre tractography: the superior frontal gyrus, medial orbitofrontal cortex, rostral middle frontal gyrus, precuneus and isthmus cingulate. Structural connectivity was assessed in pathways connecting these regions to the ACC using three diffusion MRI derived measures: fractional anisotropy (FA), mean diffusivity (MD) and apparent fibre density (AFD), and compared between participant groups. Furthermore we investigated correlations of these measures with executive function as assessed by the Flanker task. The ACC-precuneus tract had significantly different MD (p < 0.0001) and AFD (p = 0.0072) between groups, with post-hoc analysis showing significantly increased MD in the right hemisphere of children with left hemiparesis compared with controls. The ACC-superior frontal gyrus tract had significantly different FA (p = 0.0049) and MD (p = 0.0031) between groups. AFD in this tract (contralateral to side of hemiparesis; right hemisphere in controls) showed a significant relationship with Flanker task performance (p = 0.0045, β = -0.5856), suggesting that reduced connectivity correlates with executive dysfunction. Reduced structural integrity of ACC tracts appears to be important in UCP, in particular the connection to the superior frontal gyrus. Although damage to this area is heterogeneous it may be important in early identification of children with impaired executive function.