Neonatal outcomes of two-step delivery in low-risk pregnancy: A prospective observational study.

AIM: Extraction of the fetal body is typically performed immediately after delivery of the head in Western obstetric care. Reports justifying immediate extraction are few. Two-step delivery entails waiting for the next uterine contraction after delivery of the head. The present study evaluates neonatal asphyxia and respiratory impairment in two-step delivery using the head-to-body delivery interval. METHODS: This prospective observational study performed at a single birth clinic used the data of 262 low-risk pregnant women with two-step delivery. We measured the time interval of head-to-body delivery and correlation analysis and simple linear regression analysis between the head-to-body delivery interval and umbilical artery pH. The women were divided into two groups according to the head-to-body delivery interval: ≤60 or >60 s. The prevalence of neonatal asphyxia and neonatal respiratory impairment was compared between the groups. RESULTS: The mean head-to-body delivery interval was 88.9 ± 71.3 s. The umbilical artery pH tended to decrease with increasing head-to-body delivery interval; however, there was almost no correlation and the decline of pH was only 0.010 for every additional minute. Low Apgar score incidence at 5 min did not differ significantly between the groups. No cases of shoulder dystocia were reported, and tachypnea at 4 h after birth occurred in 3% of the births. CONCLUSIONS: A longer head-to-body delivery interval is not associated with negative outcomes in two-step delivery. We believe that two-step delivery could have some superior outcomes compared with one-step delivery outcomes, particularly as to improving fetal circulation and preventing shoulder dystocia.

Repair of damaged ligaments with tissue fixation system minisling is sufficient to cure major prolapse in all three compartments: 5-year data.

AIM: The ageing population in Japan brings problems of pelvic organ prolapse (POP), bladder and bowel incontinence, and fragility as regards major pelvic surgery. Existing data from tissue fixation system (TFS) surgery show high cure rates for these conditions, but long-term data are lacking. We aimed to elucidate the usefulness of TFS by assessing 5-year postoperative outcomes. METHODS: A total of 68 patients, mean age 70 years, underwent total pelvic floor repair. Cystocele, apical prolapse, and rectocele were variously addressed by TFS repair of pubourethral, arcus tendineus fasciae pelvis, cardinal, uterosacral, and perineal body ligaments using a mean 3.2 tapes per patient (n = 216). Patients were followed up at 12 months then yearly. We included patients with third- or fourth-degree uterine/vaginal prolapse (POP Quantification classification). We excluded patients with serious comorbid conditions. RESULTS: The mean operating time was 88 min and the mean blood loss was 78 mL. There was minimal postoperative pain and urinary retention, as evidenced by a mean hospital stay of 0.8 days and early return to normal activities. The 5-year cure rates for urinary stress incontinence, urgency, nocturia, and frequency were 82%, 91.7%, 58%, and 52%, respectively. The surgical cure rate for POP was 87.1% at 12 months, falling to 79.0 at 60 months. The cumulative 5-year erosion rate was 0% and 1.7% for all ligaments except the perineal body (25.7%), reducing to 2.6% by year 5 following anchor placement into deep transversus perinei. Two cases of ileus were attributed to incorrect technique. CONCLUSION: Reinforcing up to four ligaments with the TFS was sufficient for cure of third- and fourth-degree POP. The technique is minimally invasive, suitable for elderly women, and effective at 5 years for both anatomical and symptom cure.

Effect of ecabet sodium treatment on urea breath test and stool antigen tests in volunteers with Helicobacter pylori infection.

BACKGROUND AND AIM: Ecabet sodium is reported to have a bactericidal effect on Helicobacter pylori and inhibit urease activity in vitro. METHODS: Seven male volunteers (mean age, 51.3 years; range, 45-55 years) with H. pylori infection were medicated with 1 g ecabet sodium t.i.d. for 4 weeks. The urea breath test (UBT) was performed 10 times per person: before medication, seven times in 2 weeks, and once in the third and fourth weeks. Stool antigen tests (HpSA PLUS and Testmate pylori antigen) were performed five times per person: before medication and weekly during medication. RESULTS: The premedication UBT value ranged from 4.9 ‰ to 77.4 ‰ and from 2.9 ‰ to 44 ‰ at the end of the treatment period. Not one of the subjects had a negative UBT result during medication. The optical densities of the HpSA and Testmate pylori antigen tests ranged from 0.4 to > 3.0 premedication and from 0.0 to > 3.0 at the end of treatment. HpSA and Testmate pylori antigen were negative in two cases. CONCLUSIONS: In this study, ecabet sodium did not effect the results of UBT in volunteers with H. pylori infection. Ecabet sodium may influence stool antigens because in two of seven cases the H. pylori stool antigen tests returned negative results.

Anxiety or Nervousness Disturbs the Progress of Birth Based on Human Behavioral Evolutionary Biology.

In general, anxiety or nervousness in pregnant women increases the risk of dystocia. Pregnant women are easily susceptible to anxiousness or nervousness. To support a safe and healthy birthing process, childbirth educators, other health-care professionals, and pregnant women require an in-depth understanding about the disruptive effects of anxiety or nervousness on birth progress. Anxiety and nervousness are difficult to quantify and may be influenced by culture. Therefore, reports comparing anxiety or nervousness with dystocia must include various biases. It is difficult to find this issue by medical research. Here, we discuss links between anxiety or nervousness and disturbance in the progress of birth based on the adaptive standpoint of human behavioral evolutionary biology.

Hyperthermic stimulation of blood increases the immunological effects of granulocyte and monocyte adsorption in vitro: relevance to extracorporeal immunomodulation.

Extracorporeal granulocyte and monocyte/macrophage adsorption (GMA) using an adacolumn filled with cellulose acetate beads as GMA carriers selectively depletes excess and activated myeloid leucocytes from the circulation and has been used as a non-pharmacologic adjunct therapy in patients with inflammatory bowel disease (IBD). In this study we applied hyperthermic stimulation of blood during exposure to the GMA carriers with the aim of enhancing the release of anti-inflammatory substances from leucocytes. In blood from patients with Crohn's disease (CD) and healthy controls (HC), incubation with the carriers was associated with a striking increase in the release of interleukin-1 receptor antagonist (IL-1ra, a powerful anti-inflammatory cytokine) independent of hyperthermic stimulation, while in the blood from both CD and HC, the release of heat shock protein70 (Hsp70, a cytoprotective protein) was increased by two fold. The present data indicate that hyperthermic stimulation of blood at 43 degrees C or exposure to cellulose acetate carriers is a simple strategy to generate substances of therapeutic potential from blood, especially in patients with IBD. These observations are very interesting in the context of extracorporeal immunomodulation in patients with immune pathology.

Cytapheresis as a Non-Pharmacological Therapy for Inflammatory Bowel Disease.

SUMMARY: Although inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), is a chronic recurrent disease with unknown etiology. Recent immunological studies suggest close relation to autoimmune status featured by antibodies against colonic epithelial cells. For patients with IBD, 5-aminosalycilates are often used in case of mild disease, and corticosteroids are standard therapy for moderate-to-severe disease. However, we often encounter patients who are resistant to or dependent of conventional therapy, which are likely to lead to future problems in quality of life due to adverse effects of drugs used, especially corticosteroids. Extracorporeal leukocyte removal therapy (cytapheresis) is one of the adjunctive therapies for IBD patients refractory to steroids. By removing circulating activated leukocytes, especially granulocytes and lymphocytes, impaired immune response is suppressed. In the present article recently published studies are reviewed in order to reflect the current state of the art in the use of cytapheresis for treating IBD, especially UC and CD. Although there are only few randomized controlled trials, clinical experience so far suggests that cytapheresis has superior efficiency than conventional therapies in steroid-resistant moderate-to-severe UC. Moreover, cytapheresis features its safety characteristic compared with other conventional medications for severe UC, cytapheresis is regarded as safe treatment regimen.

Spontaneous uterine laceration in labor: a type of intrapartum uterine injury different from the classical uterine rupture.

Uterine rupture, a complete disruption of uterine wall, is synonymously used of intrapartum uterine corpus injuries. However, uterine laceration, partial and minor myometrial tear, is not well characterized. A 35-year-old Japanese woman with unscarred uterus was delivered of a baby at 38 gestational weeks. Shortly after delivering the placenta, she complained of severe lower abdominal pain with shock vitals. Exploratory laparotomy revealed a partial and shallow myometrial and serosal tear with massive hemoperitoneum. Despite its shallow and minor nature of the injury, uterine laceration can cause a catastrophic massive hemoperitoneum and should be noted as a type of intrapartum uterine injury in clinical practice.

Activated platelets as a possible early marker to predict clinical efficacy of leukocytapheresis in severe ulcerative colitis patients.

BACKGROUND: Leukocytapheresis (LCAP) is an effective adjunct for patients with active ulcerative colitis (UC). Because LCAP may have the potential to remove and modulate not only leukocytes but also platelets, we evaluated the correlation between activated platelets and the therapeutic response to LCAP. METHODS: Fourteen patients with severe UC received weekly LCAP for 5 consecutive weeks. Their average clinical activity index (CAI) and endoscopic index (EI) were 9.6 +/- 3.4 and 10.9 +/- 1.0, respectively. Their peripheral blood was sampled before and after every LCAP and stained with fluorescent antibodies to the activation-dependent surface antigens of platelets (CD63, CD62-P) prior to flow cytometry. Endoscopic evaluations were performed after the last LCAP. RESULTS: Clinical remission (CAI < 4) was induced in 50% of the patients (7/14) after 5 weeks, and there were no significant differences observed in clinical background between the responder group (RG) and the nonresponder group (NG). In the RG, the populations of CD63(+) (P < 0.03) and CD62-P(+) (P < 0.05) platelets were significantly decreased after the first LCAP, and their reduction ratio decreased gradually with repeated LCAP. A significant improvement of the EI score, especially mucosal damage, was achieved in RG (P < 0.04) but not in NG. CONCLUSIONS: These results indicate that the therapeutic responses to LCAP were reflected in modulations of population and/or platelet functions, especially after the first session. The decrease of such activated platelets immediately after the first LCAP may be an early marker for predicting the response in patients with severe UC.

Laparoscopic Management of Abdominal Pregnancy with Local Injection of Vasopressin Solution: A Case Report.

BACKGROUND Laparoscopic treatments of abdominal pregnancy have been reported; however, resection of an implanted gestational sac could lead to massive bleeding and treatment failure. Hemostasis of the resected stump is critical for the success of laparoscopic treatment. CASE REPORT A 32-year-old woman presented to the emergency department with severe abdominal pain. We suspected a ruptured ectopic pregnancy and performed urgent diagnostic laparoscopy. The gestational sac was implanted in the posterior wall of the uterus near the left uterosacral ligament, and bleeding from the gestational sac was noticed. We injected 3 ml of diluted vasopressin solution (0.4 U/ml) directly into the gestational sac and into the posterior uterine wall around the gestational sac. Thereafter, we could resect the gestational product using an ultrasonically activated scalpel. Additional hemostasis in the resected stump was not required. CONCLUSIONS We believe that a local injection of a diluted vasopressin solution helps in maintaining the hemostasis after the laparoscopic resection of the implanted gestational sac in cases of abdominal pregnancy.

Detection of specific IgE antibodies to nafamostat mesilate as an indication of possible adverse effects of leukocytapheresis using nafamostat mesilate as anticoagulant.

The aim was to determine whether adverse effects of leukocytapheresis (LCAP) are related to nafamostat mesilate (NM) as an anticoagulant. Anti-NM IgE were detected in inflammatory bowel disease (IBD) patients who were administrated LCAP in our institute. Forty-nine patients (ulcerative colitis (UC)/Crohn's disease (CD): 30/19) were evaluated. Anti-NM IgE was measured by the ELISA method. Total IgE level and eosinophil count was tested concurrently. We retrospectively checked the presence of allergic symptoms and medications used concurrently with LCAP. Anti-NM IgE were present in six symptomatic patients (6/49; 12.2%) whose adverse effects were highly suspected to be from NM. However, 21 patients showed anti NM IgE-negative, in spite of the fact that their adverse effects were also highly suspected to be from NM. Through the detection of anti-NM IgE alone we could not estimate the relevance of NM as an anticoagulant to the adverse effects of LCAP.

Cytapheresis in patients with severe ulcerative colitis after failure of intravenous corticosteroid: a long-term retrospective cohort study.

BACKGROUND/AIMS: Cytapheresis (CAP) is a novel strategy for ulcerative colitis (UC). However, there is insufficient data on the long-term outcome of UC patients who achieve remission by CAP. This study involved patients with severe UC who refracted to intravenous (iv) corticosteroid. METHODS: Forty-seven UC patients who had received CAP therapy for the first time within 1 year after UC diagnosis were followed for 36 months. One of the inclusion criteria was a clinical activity index (CAI) of >/=7 points at the end of a 2-week iv course of corticosteroid therapy. CAP therapy consisted of ten sessions over 10 weeks. RESULTS: CAP induced clinical remission (CAI/=12, n=25) than for moderately severe UC at entry (7

Multivariate analysis for factors predicting rapid response of leukocytapheresis in patients with steroid-resistant ulcerative colitis: a multicenter prospective open-label study.

Leukocytapheresis (LCAP) has been advocated as a treatment for moderate to severe active ulcerative colitis (UC) in Japan. To clarify the predictive factors for a rapid response to LCAP treatment, we conducted a multicenter prospective open-label study. A total of 105 patients with UC were analyzed. LCAP was performed using a Cellsorba EX column once a week for 5-10 sessions. The response was evaluated by the clinical activity index (CAI). When the CAI score decreased to less than half the pretreatment value or to less than 5 points within 3 weeks, the patient was considered to be a rapid responder. The average CAI significantly decreased from 11.7 to 4.2 (P < 0.01). Seventy-four percent of the patients responded to the therapy, and 53% of these patients were rapid responders. The following significant factors correlated with the rapid LCAP response: (i) steroid resistance (P < 0.05), (ii) severe disease indicated by a CAI score greater than 11 (P = 0.05), (iii) disease duration of less than 1 year (P < 0.05), and (iv) C-reactive protein levels before treatment (P < 0.01). These results suggest that the early initiation of LCAP is beneficial in patients with steroid-resistant UC.

Demonstration of low-regulatory CD25High+CD4+ and high-pro-inflammatory CD28-CD4+ T-Cell subsets in patients with ulcerative colitis: modified by selective granulocyte and monocyte adsorption apheresis.

Low-CD25(High+)CD4(+), a subset of regulatory CD25(+)CD4(+) T cells and high-inflammatory CD28(-)CD4(+) T cells can exacerbate ulcerative colitis (UC). This study sought to investigate the frequency of CD25(High+)CD4(+) and CD28(-)CD4(+) T cells in patients with UC and the changes in these cells during Adacolumn granulocyte and monocyte adsorption apheresis (GMA). Subjects were 12 patients with active UC, 11 with quiescent UC, and 14 healthy volunteers (HVs). The mean clinical activity index was 15.7 +/- 2.2 in active UC and 4.5 +/- 1.1 in quiescent UC. Peripheral blood samples were stained with CD4, CD25, and CD28 antibodies for flow cytometry. Patients with active UC received GMA and blood samples were examined before and after the first GMA session. Patients with active UC (P < 0.04) or quiescent UC (P < 0.02) had a higher percentage of CD28(-)D4(+)T cells compared with HVs, while the percentage of CD28(+)CD4(+) T cells was lower in both UC groups compared with HVs (P = 0.03 and P < 0.02). Patients with active UC had a lower percentage of CD25(High+)CD4(+)T cells compared with quiescent UC patients (P < 0.001). A significant increase in CD25(High+)CD4(+) T cells was associated with GMA (P < 0.03). Low CD25(High+)CD4(+) and high CD28(-)CD4(+) are prominent features in UC. The increase in CD25(High+)CD4(+) T cells induced by GMA should contribute to improved immune function. Additional studies are warranted, since a low frequency of CD25(High+)CD4(+) (-) and a high frequency of CD28(-)CD4(+) (-) expressing T cells might be a predictor of clinical response to GMA.

Leukocytapheresis (LCAP) for management of fulminant ulcerative colitis with toxic megacolon.

Leukocytapheresis (LCAP) is a method of therapeutic apheresis to remove patients' peripheral leukocytes by extracorporeal circulation. Previous studies showed that LCAP for the treatment of ulcerative colitis (UC) was more effective and had fewer adverse effects compared to high-dose steroid therapy. However, there are no reports on the application of LCAP for UC patients with toxic megacolon (TM). This study reports the effectiveness and safety of LCAP in treating patients with severe or fulminant UC with TM. Six patients were enrolled in this study and LCAP sessions were performed three times per week for 2 weeks, followed by four further times in the next 4 weeks. After completion of therapy, four patients improved in TM and went into the remission stage of UC. The average Rachmilewitz clinical activity index of these four patients improved from 19.5 to 1. The remaining two patients had to undergo colectomy, however, the symptoms had been mitigated by LCAP and the operations were completed without any problems. These results suggest that LCAP is an additional effective and safe option for TM management in preventing colectomy or for bridging to a safer operation.

Analyses of factors contributing to vulnerability to antenatal periventricular leukomalacia induced by hemorrhagic hypotension in chronically instrumented fetal sheep.

Our purpose was to determine factors contributing to vulnerability to antenatal periventricular leukomalacia (PVL) induced by hemorrhagic hypotension in premature fetal sheep. Systemic hypotension was induced in 10 fetal sheep by acutely withdrawing 35% to 40% of the fetoplacental blood volume at 113 d gestation. Brains were processed for histologic analysis 6 d after the insult. Statistical comparisons of physiologic parameters between fetuses suffering from PVL (n = 5) and those without PVL (n = 5) were performed. Significant correlations were found between induction of PVL and fetal brain weight, changes in fetal mean blood pressure over time, base excess, oxygen content, hematocrit, and plasma arginine vasopressin (AVP) levels in fetal abdominal aortic blood. Brain developmental stage, the magnitude of induced systemic hypotension, and baseline blood oxygen content were important intrinsic factors in the induction of antenatal PVL by hemorrhagic hypotension in premature fetal sheep.

Adsorptive Monocyte-granulocytapheresis (M-GCAP) for refractory Crohn's disease.

Six patients with active Crohn's disease (CD) unresponsive to conventional medications (CM) were treated with Monocyte-granulocytapheresis (M-GCAP). CD patients who scored 200-400 points in Crohn's disease activity index (CDAI) in spite of receiving CM, including enteral nutrition, for at least 2 weeks were enrolled in our double series trial. Each series had 5 weekly M-GCAP and 2 follow-up weeks, and each M-GCAP treated 1,800 ml of patient's peripheral blood. After the 1st series, patients who decreased more than 50 points on the CDAI were deemed responders and enrolled in the second series. Patients with a CDAI score less than 150 points were considered in remission. The patients' quality of life was evaluated using an index (IBDQ) before and after the 1st series. The CDAI was significantly decreased comparing before and after the 1st series (258.2 +/- 36.2 vs. 166.5 +/- 16.6; P < 0.02). 50% of patients (3/6) responded to the therapy, and one case (16.7%) could be induced to remission. Significant removal was revealed only for white blood cells (25.6 +/- 16.9%; P < 0.05), especially granulocytes (29.5 +/- 22.5%; P < 0.05). A statistically significant improvement of IBDQ was revealed in the responders' group (162.3 +/- 17.2 vs. 189.3 +/- 11.5; P < 0.03). M-GCAP could be an effective adjunctive therapy for active CD patients unresponsive to CM allowing them to maintain a high QOL. However, it might be difficult to improve patients who could not be induced to remission after the 1st series by applying another series.