BIRTH INJURY, DUCHENNE-ERBʼS OBSTETRIC PALSY. DIAGNOSIS AND TREATMENT (LITERATURE REVIEW)

Authors

  • Sergij Khmyzov Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine https://orcid.org/0000-0002-6725-0915
  • Anastasiia Hrytsenko Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
  • Genadii Kykosh Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine
  • Anton Hrytsenko Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv, Ukraine

DOI:

https://doi.org/10.15674/0030-59872023369-78

Keywords:

Obstetric palsy, brachial plexus, tendon-muscle transpositions, osteotomy, botulinum toxin

Abstract

Obstetric practice dates back thousands of years, providing assistance to women in labor is often complicated by the rapid course of labor, pelvic presentation of the fetus, shoulder dystocia with a possible clavicle fracture. Damage to CV–CVI roots, classic Duchenne–Erb palsy, accounts for 46 % of the total number of obstetric palsies. Objective. To analyze the scientific and medical literature in order to identify historical scientific and practical information about the study of childbirth injuries, and, in particular, Duchenne–Erb's obstetric palsy. Methods. To study and analyze sources of scientific and medical information, publications from Google search engines, electronic databases PubMed, Google Scholar, archival medical journals. Results. The first data on obstetric paralysis were provided by Duchesne in 1872, highlighting thorough reports on upper extremity muscle damage. Subsequently, in 1874, Erb performed electrical stimulation of the affected muscles, finding out the zone of neurological damage. The history of the development and formation of this scientific issue is quite ambiguous, because it borders on two medical fields: neurosurgery and orthopedics. According to literary sources, it is obvious that the pathohistology and pathophysiology of the direct injury zone (roots CV–CVI), delayed changes in the function of the upper limb, and the latest diagnostic technologies simplify the understanding of the presentation. The existing methods of operative interventions allow physicians to improve the child's life. However, the question remains open regarding the use of certain operative interventions in relation to the child's age and further rehabilitation. Conclusions. Despite a significant stratum of scientific and practical research on Duchenne–Erb's obstetric palsy, there are still a number of questions regarding the diagnosis and treatment of children with this abnormality. The search for improving the functional state of the upper limb in children should continue.

Author Biographies

Sergij Khmyzov, Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv

MD, Prof. in Traumatology and Orthopaedics

Anastasiia Hrytsenko, Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv

MD

Genadii Kykosh, Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv

MD, PhD in Traumatology and Orthopaedics

Anton Hrytsenko, Sytenko Institute of Spine and Joint Pathology National Academy of Medical Sciences of Ukraine, Kharkiv

MD

References

  1. O’Berry, P., Brown, M., Phillips, L., & Evans, S. H. (2017). Obstetrical Brachial Plexus Palsy. Current Problems in Pediatric and Adolescent Health Care, 47 (7), 151–155. https://doi.org/10.1016/j.cppeds.2017.06.003
  2. Hoeksma, A. F., Wolf, H., & Oei, S. L. (2000). Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture. Clinical Rehabilitation, 14 (5), 523–526. https://doi.org/10.1191/0269215500cr341oa
  3. Pollack, R. N., Buchman, A. S., Yaffe, H., & Divon, M. Y. (2000). Obstetrical Brachial Palsy: Pathogenesis, Risk Factors, and Prevention. Clinical Obstetrics and Gynecology, 43 (2), 236–246. https://doi.org/10.1097/00003081-200006000-00003
  4. Mollberg, M., Wennergren, M., Bager, B., Ladfors, L., & Hagberg, H. (2007). Obstetric brachial plexus palsy: a prospective study on risk factors related to manual assistance during the second stage of labor. Acta Obstetricia et Gynecologica Scandinavica, 86 (2), 198–204. https://doi.org/10.1080/00016340601089792
  5. Doumouchtsis, S. K., & Arulkumaran, S. (2009). Are All Brachial Plexus Injuries Caused by Shoulder Dystocia? Obstetrical & Gynecological Survey, 64 (9), 615–623. https://doi.org/10.1097/ogx.0b013e3181b27a3a
  6. Belabbassi, H., Imouloudene, A., & Kaced, H. (2020). Risk factors for obstetrical brachial plexus palsy. Mustansiriya Medical Journal, 19 (1), 30. https://doi.org/10.4103/mj.mj_2_20
  7. Weiss, C., Oppelt, P., & Mayer, R. B. (2018). Disadvantages of a weight estimation formula for macrosomic fetuses: the Hart formula from a clinical perspective. Archives of Gynecology and Obstetrics, 298 (6), 1101–1106. https://doi.org/10.1007/s00404-018-4917-z
  8. Mollberg, M., Hagberg, H., Bager, B., Lilja, H., & Ladfors, L. (2005). Risk Factors for Obstetric Brachial Plexus Palsy Among Neonates Delivered by Vacuum Extraction. Obstetrics & Gynecology, 106 (5, Part 1), 913–918. https://doi.org/10.1097/01.aog.0000183595.32077.83
  9. Sandmire, H. F., & DeMott, R. K. (2002). Erb's Palsy Causation: A Historical Perspective. Birth, 29 (1), 52–54. https://doi.org/10.1046/j.1523-536x.2002.00156.x
  10. Torki, M., Barton, L., Miller, D. A., & Ouzounian, J. G. (2012). Severe Brachial Plexus Palsy in Women Without Shoulder Dystocia. Obstetrics & Gynecology, 120 (3), 539–541. https://doi.org/10.1097/aog.0b013e318264f644
  11. Kawabata, H. (2000). Brachial plexus surgery in obstetrical paralysis. Brachial Plexus Palsy (рр. 302–319). World Scientific. https://doi.org/10.1142/9789812813701_0011
  12. Al-Qattan, M. M. (2003). Obstetric Brachial Plexus Palsy Associated With Breech Delivery. Annals of Plastic Surgery, 51 (3), 257–264. https://doi.org/10.1097/01.sap.0000063750.16982.e4
  13. Gosk, J., Wnukiewicz, W., & Urban, M. (2014). The effect of perinatal brachial plexus lesion on upper limb development. BMC Musculoskeletal Disorders, 15 (1). https://doi.org/10.1186/1471-2474-15-116
  14. Singh, A., Singh, A., Balasubramanian, S., & Orozco, V. (2020). A Systematic Review of the Electrodiagnostic Assessment of Neonatal Brachial Plexus Palsy. Neurology and Neurobiology, 1–11. https://doi.org/10.31487/j.nnb.2020.02.12
  15. Bertelli, J., Soldado, F., Ghizoni, M. F., & Rodríguez-Baeza, A. (2015). Transfer of a Terminal Motor Branch Nerve to the Flexor Carpi Ulnaris for Triceps Reinnervation: Anatomical Study and Clinical Cases. The Journal of Hand Surgery, 40 (11), 2229–2235. e2. https://doi.org/10.1016/j.jhsa.2015.08.014
  16. Andrisevic, E., Taniguchi, M., Partington, M. D., Agel, J., & Van Heest, A. E. (2014). Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy. Journal of Neurosurgery: Pediatrics, 13 (2), 229–237. https://doi.org/10.3171/2013.10.peds1345
  17. Hsiao, E. C., Fox, I. K., Tung, T. H., & Mackinnon, S. E. (2008). Motor Nerve Transfers to Restore Extrinsic Median Nerve Function: Case Report. HAND, 4 (1), 92–97. https://doi.org/10.1007/s11552-008-9128-9
  18. Maggi, S. P., Lowe, J. B., & Mackinnon, S. E. (2003). Pathophysiology of nerve injury. Clinics in Plastic Surgery, 30 (2), 109–126. https://doi.org/10.1016/s0094-1298(02)00101-3
  19. Kamble, N., Shukla, D., & Bhat, D. (2019). Peripheral nerveinjuries: Electrophysiology for the Neurosurgeon. Neurology India, 67 (6), 1419. https://doi.org/10.4103/0028-3886.273626
  20. Billet, F., Caillaud, M., Richard, L., Vallat, J.-M., & Desmoulière, A. (2019). Peripheral nerve regeneration and intraneural revascularization. Neural Regeneration Research, 14 (1), 24. https://doi.org/10.4103/1673-5374.243699
  21. Sunderland, S. (1969). Nerves and nerve injuries. Livingstone.
  22. Bonnard, C., & Slooff, B. (1999). Brachial Plexus Lesions. Springer Berlin Heidelberg. https://doi.org/10.1007/978-3-642-58378-0
  23. Narakas, A. O. (1991). Brachial Plexus Injuries. Neurocirugía, 2 (3), 283. https://doi.org/10.1016/s1130-1473(91)71166-4
  24. Al-Qattan, M. M., El-Sayed, A. A. F., Al-Zahrani, A. Y., Al-Mutairi, S. A., Al-Harbi, M. S., Al-Mutairi, A. M., & Al-Kahtani, F. S. (2009). Narakas classification of obstetric brachial plexus palsy revisited. Journal of Hand Surgery (European Volume), 34 (6), 788–791. https://doi.org/10.1177/1753193409348185
  25. Hale, H. B., Bae, D. S., & Waters, P. M. (2010). Current Concepts in the Management of Brachial Plexus Birth Palsy. The Journal of Hand Surgery, 35(2), 322–331. https://doi.org/10.1016/j.jhsa.2009.11.026
  26. Jennett, R. J., Tarby, T. J., & Krauss, R. L. (2002). Erb's palsy contrasted with Klumpke's and total palsy: Different mechanisms are involved. American Journal of Obstetrics and Gynecology, 186 (6), 1216–1220. https://doi.org/10.1067/mob.2002.123743
  27. Hoeksma, A. F., Wolf, H., & Oei, S. L. (2000). Obstetrical brachial plexus injuries: incidence, natural course and shoulder contracture. Clinical Rehabilitation, 14 (5), 523–526. https://doi.org/10.1191/0269215500cr341oa
  28. Abid, A. (2016). Brachial plexus birth palsy: Management during the first year of life. Orthopaedics & Traumatology: Surgery & Research, 102 (1), S125—S132. https://doi.org/10.1016/j.otsr.2015.05.008
  29. Dixit, N. N., McFarland, D. C., & Saul, K. R. (2019). Computational analysis of glenohumeral joint growth and morphology following a brachial plexus birth injury. Journal of Biomechanics, 86, 48–54. https://doi.org/10.1016/j.jbiomech.2019.01.040
  30. Frade, F., Gómez-Salgado, J., Jacobsohn, L., & Florindo-Silva, F. (2019). Rehabilitation of Neonatal Brachial Plexus Palsy: Integrative Literature Review. Journal of Clinical Medicine, 8 (7), 980. https://doi.org/10.3390/jcm8070980
  31. Santamato, A., Panza, F., Ranieri, M., & Fiore, P. (2011). Effect of botulinum toxin type A and modified constraint-induced movement therapy on motor function of upper limb in children with obstetrical brachial plexus palsy. Child's Nervous System, 27 (12), 2187–2192. https://doi.org/10.1007/s00381-011-1609-4
  32. van Dijk, J., Pondaag, W., Malessy, M., DeMatteo, C., Bain, J., Gjertsen, D., Galea, V., Deonna, T., Roulet-Perez, E., Chappuis, H., & Ziegler, A.-L. (2007). Letters to the Editor. Developmental Medicine & Child Neurology, 49 (4), 318–320. https://doi.org/10.1111/j.1469-8749.2007.00318.x
  33. Al-Qattan, M. M., & El-Sayed, A. A. F. (2014). Obstetric Brachial Plexus Palsy: The Mallet Grading System for Shoulder
  34. Function—Revisited. BioMed Research International, 1–3. https://doi.org/10.1155/2014/398121
  35. Malessy, M. J. A., Pondaag, W., & van Dijk, J. G. (2009). Electromyography, Nerve Action Potential, And Compound Motor Action Potentials In Obstetric Brachial Plexus Lesions. Neurosurgery, 65 (suppl_4), A153–A159. https://doi.org/10.1227/01.neu.0000338429.66249.7d
  36. Malessy, M. J. A., Pondaag, W., Yang, L. J. S., Hofstede-Buitenhuis, S. M., le Cessie, S., & van Dijk, J. G. (2011). Severe Obstetric Brachial Plexus Palsies Can Be Identified at One Month of Age. PLoS ONE, 6 (10), e26193. https://doi.org/10.1371/journal.pone.0026193
  37. van Dijk, J. G., Pondaag, W., Buitenhuis, S. M., van Zwet, E. W., & Malessy, M. J. A. (2012). Needle electromyography at 1 month predicts paralysis of elbow flexion at 3 months in obstetric brachial plexus lesions. Developmental Medicine & Child Neurology, 54 (8), 753–758. https://doi.org/10.1111/j.1469-8749.2012.04310.x
  38. Sibinski, M., Woźniakowski, B., Drobniewski, M., & Synder, M. (2010). Secondary gleno-humeral joint dysplasia in children with persistent obstetric brachial plexus palsy. International Orthopaedics, 34 (6), 863–867. https://doi.org/10.1007/s00264-010-0965-0
  39. Bhardwaj, P., Burgess, T., Sabapathy, S. R., Venkataramani, H., & Ilayaraja, V. (2013). Correlation Between Clinical Findings and CT Scan Parameters for Shoulder Deformities in Birth Brachial Plexus Palsy. The Journal of Hand Surgery, 38 (8), 1557–1566. https://doi.org/10.1016/j.jhsa.2013.04.025
  40. Kennedy, R. (1903). Suture of the brachial plexus in birth paralysis of the upper extremity. BMJ, 1 (2197), 298–301. https://doi.org/10.1136/bmj.1.2197.298
  41. Fairbank, H. A. T., Lond, M. S., & Eng, F. R. C. S. (1913). A Lecture On Birth Palsy : Subluxation Of The Shoulder-Joint In Infants And Young Children. The Lancet, 181 (4679), 1217–1223. https://doi.org/10.1016/s0140-6736(00)52017-0
  42. Linskey, M. E., & Kuo, J. V. (2011). General and Historical Considerations of Radiotherapy and Radiosurgery. Youmans Neurological Surgery (рр. 2547–2555). Elsevier. https://doi.org/10.1016/b978-1-4160-5316-3.00250-1
  43. Stutz, C. (2021). Management of Brachial Plexus Birth Injuries: Erbs and Extended Erbs Palsy. Operative Brachial Plexus Surgery (рр. 583–590). Springer International Publishing. https://doi.org/10.1007/978-3-030-69517-0_51
  44. Seddon, H. J. (1947). The use of autogenous grafts for the repair of large gaps in peripheral nerves. British Journal of Surgery, 35 (138), 151–167. https://doi.org/10.1002/bjs.18003513808
  45. Jensen, K., & Kannas, S. (2021). The Role of Therapy: Pre- and Post-surgery Protocols. Operative Brachial Plexus Surgery (рр. 427–448). Springer International Publishing. https://doi.org/10.1007/978-3-030-69517-0_39
  46. Gilbert, A., Pivato, G., & Kheiralla, T. (2006). Long-term results of primary repair of brachial plexus lesions in children. Microsurgery, 26 (4), 334–342. https://doi.org/10.1002/micr.20248
  47. Makeľ, M., Sukop, A., Kachlík, D., Waldauf, P., Whitley, A., & Kaiser, R. (2022). Possible donor nerves for axillary nerve reconstruction in dual neurotization for restoring shoulder abduction in brachial plexus injuries: a systematic review and meta-analysis. Neurosurgical Review, 45 (2), 1303–1312.
  48. https://doi.org/10.1007/s10143-021-01713-z
  49. Gu, Y.-D., Chen, D.-S., Zhang, G.-M., Cheng, X.-M., Xu, J.-G., Zhang, L.-Y., Cai, P.-Q., & Chen, L. (1998). Long-Term Functional Results of Contralateral C7 Transfer. Journal of Reconstructive Microsurgery, 14 (01), 57–59. https://doi.org/10.1055/s-2007-1006902
  50. Terzis, J. K., & Kokkalis, Z. T. (2008). Primary and secondary shoulder reconstruction in obstetric brachial plexus palsy. Injury, 39 (3), 5–14. https://doi.org/10.1016/j.injury.2008.06.001
  51. Soucacos, P. N., Vekris, M. D., Zoubos, A. B., & Johnson, E. O. (2006). Secondary reanimation procedures in late obstetrical brachial plexus palsy patients. Microsurgery, 26 (4), 343–351. https://doi.org/10.1002/micr.20249
  52. van Heest, A., Glisson, C., & Ma, H. (2010). Glenohumeral Dysplasia Changes After Tendon Transfer Surgery in Children With Birth Brachial Plexus Injuries. Journal of Pediatric Orthopaedics, 30 (4), 371–378. https://doi.org/10.1097/bpo.0b013e3181d8d34d
  53. de Luna Cabrai, J. R., Crepaldi, B. E., de Sambuy, M. T. C., da Costa, A. C., Abdouni, Y. A., & Chakkour, I. (2012). Evaluation of upper-limb function in patients with obstetric palsy after modified sever-l'episcopo procedure. Revista Brasileira de Ortopedia (English Edition), 47 (4), 451–454. https://doi.org/10.1016/s2255-971(15)30127-0
  54. Scholten, D. J., Trasolini, N. A., & Waterman, B. R. (2021). Reverse Total Shoulder Arthroplasty with Concurrent Latissimus Dorsi Tendon Transfer. Current Reviews in Musculoskeletal Medicine, 14 (5), 297–303. https://doi.org/10.1007/s12178-021-09715-6
  55. Bonnevialle, N., Elia, F., Thomas, J., Martinel, V., & Mansat, P. (2021). L’Ostéolyse de l’insertion du transfert tendineux de l’Episcopo: incidence et retentissement clinique. Revue de Chirurgie Orthopédique et Traumatologique, 107 (4), 506–511. https://doi.org/10.1016/j.rcot.2021.03.038
  56. Boileau, P., Trojani, C., & Chuinard, C. (2007). Latissimus Dorsi and Teres Major Transfer With Reverse Total Shoulder Arthroplasty for a Combined Loss of Elevation and External Rotation. Techniques in Shoulder and Elbow Surgery, 8 (1), 13–22. https://doi.org/10.1097/bte.0b013e31802f5047
  57. Hoffer, M. M., Wickenden, R., & Roper, B. (1978). Brachial plexus birth palsies. Results of tendon transfers to the rotator cuff. The Journal of Bone & Joint Surgery, 60 (5), 691–695. https://doi.org/10.2106/00004623-197860050-00019
  58. Pichon F., & Carlioz H. (1979). Disinsertion of the subescapular muscle in the treatment of obstetric paralysis of the upper limb (author`s transl). Chir Pediatr., 20 (02), 135–141.
  59. Ozturk, K. (2010). Reconstruction of shoulder abduction and external rotation with latissimus dorsi and teres major transfer in obstetric brachial plexus palsy. Acta Orthopaedica et Traumatologica Turcica, 186–193. https://doi.org/10.3944/aott.2010.2332
  60. Waters, P. M., & Bae, D. S. (2008). The Early Effects of Tendon Transfers and Open Capsulorrhaphy on Glenohumeral Deformity in Brachial Plexus Birth Palsy. The Journal of Bone and Joint Surgery-American Volume, 90 (10), 2171–2179. https://doi.org/10.2106/jbjs.g.01517
  61. Al-Qattan, M. M. (2003). Latissimus Dorsi Transfer for External Rotation Weakness of the Shoulder in Obstetric Brachial Plexus Palsy. Journal of Hand Surgery, 28 (5), 405–408. https://doi.org/10.1016/s0266-7681(02)00393-5
  62. Pagnotta, A., Haerle, M., & Gilbert, A. (2004). Long-term Results on Abduction and External Rotation of the Shoulder after Latissimus Dorsi Transfer for Sequelae of Obstetric Palsy. Clinical Orthopaedics and Related Research, 426, 199–205. https://doi.org/10.1097/01.blo.0000138957.11939.70
  63. Aydin, A., Ozkan, T., & Onel, D. (2004). Does preoperative abduction value affect functional outcome of combined muscle transfer and release procedures in obstetrical palsy patients with shoulder involvement? BMC Musculoskeletal Disorders, 5 (1). https://doi.org/10.1186/1471-2474-5-25
  64. Waters, P. M., & Bae, D. S. (2005). Effect Of Tendon Transfers And Extra-Articular Soft-Tissue Balancing On Glenohumeral Development In Brachial Plexus Birth Palsy. The Journal of Bone and Joint Surgery-American Volume, 87 (2), 320–325. https://doi.org/10.2106/00004623-200502000-00013
  65. Rahul K. Nath (2006). Obstetric Brachial Plexus Injuries. The Nath Method of Diagnosis and Treatment ERB’S PALSY(рр. 26–30). VBW Publishing, College Station, Texas
  66. Nath, R. K., Goel, D., & Somasundaram, C. (2019). Clinical and functional outcome of modified Quad surgery in adult obstetric brachial plexus injury patients: Case reports. Clinics and Practice, 9 (3). https://doi.org/10.4081/cp.2019.1140
  67. Rahul K. Nath (2006). Obstetric Brachial Plexus Injuries. The Nath Method of Diagnosis and Treatment ERB’S PALSY (рp. 41). VBW Publishing, College Station, Texas.
  68. Dridi, М., Safi, H., Jelel, Ch., Smida, M., Nessib, M. N., Ammar, Ch., & Ghachem, M. В. (2007). The proximal humeral osteotomy associated with the transfert of Latissimus Dorsi and Teres major in treatment of sequelae of the obstetrical brachial plexus. Tunisie Medicale [La], 85 (8), 673–678.
  69. Nath, R. K., Somasundaram, C. (2022). Comparing the Results of External Rotational Humeral Osteotomy in Older Children to the Mod Quad and Triangle Tilt Procedures in Adults with Obstetric Brachial Plexus Injury. Eplasty, 22, e2.
  70. Andrés-Cano, P., Toledo, M. Á., Farrington, D. M., & Gil, J. J. (2015). Arthroscopic treatment for internal contracture of the shoulder secondary to brachial plexus birth palsy: report of a case series and review of the literature. European Journal of Orthopaedic Surgery & Traumatology, 25 (7), 1121–1129.
  71. https://doi.org/10.1007/s00590-015-1670-x
  72. Ruyer, J., Grosclaude, S., Lacroix, P., Jardel, S., & Gazarian, A. (2018). Arthroscopic isolated capsular release for shoulder contracture after brachial plexus birth palsy: clinical outcomes in a prospective cohort of 28 children with 2 years' follow-up. Journal of Shoulder and Elbow Surgery, 27 (8), e243–e251.
  73. https://doi.org/10.1016/j.jse.2018.01.022
  74. de Luna Cabrai, J. R., Crepaldi, B. E., de Sambuy, M. T. C., da Costa, A. C., Abdouni, Y. A., & Chakkour, I. (2012). Evaluation of upper-limb function in patients with obstetric palsy after modified sever-l'episcopo procedure. Revista Brasileira de Ortopedia (English Edition), 47 (4), 451–454. https://doi.org/10.1016/s2255-4971(15)30127-0
  75. Nath, R. K., & Somasundaram, C. (2019). 10-year Follow-up of Mod Quad and Triangle Tilt Surgeries in Obstetric Brachial Plexus Injury. Plastic and Reconstructive Surgery-Global Open, 7 (1), e1998. https://doi.org/10.1097/gox.0000000000001998
  76. Nath, R. K. (2015). Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome. World Journal of Orthopedics, 6 (1), 156. https://doi.org/10.5312/wjo.v6.i1.156

How to Cite

Khmyzov, S. ., Hrytsenko, A. ., Kykosh, G. ., & Hrytsenko, A. . (2023). BIRTH INJURY, DUCHENNE-ERBʼS OBSTETRIC PALSY. DIAGNOSIS AND TREATMENT (LITERATURE REVIEW). ORTHOPAEDICS TRAUMATOLOGY and PROSTHETICS, (3), 69–78. https://doi.org/10.15674/0030-59872023369-78

Issue

Section

DIGESTS AND REVIEWS