Clinical outcomes in women with endometrial polyps underwent conservative management.

OBJECTIVE: To evaluate the regression rate of endometrial polyps (EPs) in a cohort of asymmetric women after conservative follow-up. MATERIALS AND METHODS: In this retrospective cohort study, a total of 1006 women with asymptomatic EPs were treated with expectant management or hormonal drugs between June 1999 and May 2018. Four hundred forty-eight women (44.5%) were administered with hormonal medications and 558 women were managed expectantly (55.5%). Office hysteroscopy was performed to confirm the diagnosis and regression of EPs. Hormonal administration included oral contraceptives, progestin and cyclic estrogen/progestin regimen according to physicians' preferences. Clinical characteristics, including the patient's age, body mass index, parity, and type of conservative management were collected. RESULTS: The mean observation time was 14.1 ± 18.5 months (range, 1-162 months). The overall regression rate of EPs in this cohort was 33.5%, 24.6% occurred after medication and 8.9% after expectant management. Patient age (<50 years) (p < 0.001), follow-up period (p = 0.005) and hormonal drugs used (p < 0.001) were significantly associated with EP regression. Twenty-four (7.1%) of the 337 EP regression patients later developed recurrent disease. Follow-up period (p < 0.001) and hormonal drugs used (p = 0.032) were closely related to polyp recurrence after initial regression. Nevertheless, multivariate logistic regression analysis revealed that hormonal drugs used was significantly associated with the regression (p < 0.001) and recurrence (p = 0.016) of EPs. CONCLUSION: Women aged 50 or less are more suitable for conservative treatment for EPs. Hormonal drugs used could increase the incidence of EP regression.

Hysteroscopic removal, with or without laparoscopic assistance, of first-trimester cesarean scar pregnancy.

OBJECTIVE: To demonstrate the implementation and potential benefits of hysteroscopic removal, with or without concomitant laparoscopic assistance, of first-trimester cesarean scar pregnancies (CSPs). DESIGN: Patients with prior cesarean deliveries may have scar formation at the muscular wall of the uterine isthmus, resulting in a cesarean scar defect (CSD), also known as an isthmocele or diverticulum. When implantation of a trophoblast occurs at the CSD, a CSP develops, and with progression onto higher gestational age, it carries risks for serious complications, such as placenta previa spectrum, life-threatening bleeding, uterine rupture, and cesarean hysterectomy. Therefore, early termination is often recommended. Given that the chorionic frondosum only penetrates the decidual basalis layer during the first trimester and does not invade the distal myometrial segment until early second trimester, operative hysteroscopy can be a reliable and efficient treatment modality for early intervention. This narrated video features the systematic approach and surgical management for patients with first-trimester CSPs. SETTING: Academic tertiary hospital. PATIENT(S): Three multiparous women between 34 and 38 years of age diagnosed with CSPs within the first trimester. INTERVENTION(S): Initial assessment with transvaginal ultrasonography and color Doppler flow identifies the site of implantation and measures the residual myometrial thickness (RMT), which are important parameters for classifying the CSPs into type I or type II. Type I CSPs often present at an earlier gestational age, have a thicker RMT, and grow toward the uterine cavity, while type II CSPs are frequently noted at a higher gestational age, have a thinner RMT, demonstrate obvious scar dehiscence, and often invade toward the bladder. The patients received either operative hysteroscopy alone or with concomitant laparoscopic assistance and repair of CSD dehiscence. For all hysteroscopic operations, misoprostol (200 µg) was given 4 hours before the procedure while oxytocin (20 U in 1000 mL isotonic solution, intravenous infusion) was infused immediately after removal of the placental tissue. For laparoscopic excision and repair of the dehiscent scar, local injection of 5 mL terlipressin acetate (1 mg) was added before the initiation of laparoscopic CSD excision. MAIN OUTCOME MEASURE(S): Appraisal of the parameters used for preoperative assessment, the efficacy of the surgical procedures, and the intention to minimize the associated risks and morbid sequalae were evaluated. RESULT(S): Most of the type I CSPs or type II CSPs with gestational age <8 weeks and RMT >3 mm can be successfully treated with operative hysteroscopy alone. In contrast to blind dilatation and curettage, operative hysteroscopy offers direct visualization to ensure complete removal of the chorionic villi, which can occasionally be buried deep within the concavity of the CSD. It is worth noting that gently sweeping the decidua basalis from the myometrium with the loop resectoscope is more than enough to separate the chorionic villi within and completely displace the placental tissues without causing massive hemorrhage. For type II CSPs in late first-trimesters showing distended CSDs and diminished RMT, laparoscopy can be established before the hysteroscopic procedure for better surveillance and to prevent inadvertent myometrial perforation. Then, hysteroscopic removal of CSP can further induce uterine contractions to help reduce blood loss during subsequent laparoscopic repair of CSD. CONCLUSION(S): Accurate diagnosis and timely management of CSPs during the first trimester are crucial for preventing significant morbidities associated with advanced gestational age. Operative hysteroscopy offers the benefit of direct visualization for competent detachment of the decidua basalis of the CSP from the steep concavity of the CSD. Furthermore, the employment of laparoscopy for type II CSPs helps avoid inadvertent complications related to the thin RMT and allows concomitant repair of the extensive dehiscence.

A feasibility analysis of the ArcBlate MR-guided high-intensity focused ultrasound system for the ablation of uterine fibroids.

PURPOSE: Uterine fibroids are benign gynecologic tumors and commonly occur in women by the age of 50. Women with symptomatic uterine fibroids generally receive surgical intervention, while they do not favor the invasive therapies. To evaluate the feasibility and safety of a novel magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) modality, ArcBlate, in the treatment of uterine fibroids. METHODS: Nine patients with uterine fibroids and one patient with adenomyosis were treated with ArcBlate MRgHIFU. Tumor size and quality of life were evaluated postoperatively at 1 and 3 months by magnetic resonance imaging (MRI) and the 36-Item Short Form Survey (SF-36), respectively. RESULTS: All patients completed the ArcBlate MRgHIFU procedure and there were no treatment-related adverse effects either during the procedure or during the 3 months of follow-up. Despite limiting the ablation volume to under 50% of the treated fibroid volume as a safety precaution, tumor volumes were markedly reduced in four patients by 15.78-58.87% at 3-month post-treatment. Moreover, SF-36 scale scores had improved at 3 months from baseline by 2-8 points in six patients, indicating relief of symptoms and improved quality of life. CONCLUSION: This study evidence demonstrates the safety and feasibility of ArcBlate MRgHIFU and suggests its potential for treating uterine fibroids.

Use of human fibrin glue (Tisseel) versus suture during transvaginal natural orifice ovarian cystectomy of benign and non-endometriotic ovarian tumor: a retrospective comparative study.

BACKGROUND: To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors. METHODS: A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined. RESULTS: Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210). CONCLUSION: The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Learning curve analysis of applying Seprafilm hyaluronic acid/carboxymethylcellulose membrane during laparoscopic hysterectomy.

This study was designed to evaluate the learning curve of applying Seprafilm (modified hyaluronic acid and carboxymethylcellulose; Genzyme, Cambridge, MA, USA) during laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy. In this retrospective cohort study, 35 patients who underwent laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy were enrolled. The Seprafilm was cut into 4 pieces, rolled up with a trimmed plastic sleeve and delivered through an incision wound made for the 5-mm ancillary trocar. The membrane was unrolled and placed on the rough surface after hysterectomy or subtotal hysterectomy with or without adnexectomy. The time from the insertion of the first piece of membrane into the abdominal cavity to the complete removal of the trimmed plastic sleeve was recorded. The median time for Seprafilm placement was 3 min. The learning curve was analyzed using the power-law method and suggested that 10 cases were required to achieve proficiency in the procedure. The presence of adnexectomy was significantly associated with the time required for Seprafilm placement (P < 0.001). Although Seprafilm placement is more complicated compared to the liquid and gel forms of anti-adhesion barriers, surgical proficiency seemed to be attained after 10 cases for an experienced surgeon.

Measuring patient-reported outcomes in orthognathic surgery: Linguistic and psychometric validation of the Mandarin Chinese version of FACE-Q instrument.

BACKGROUND: Orthognathic surgery is useful for correction of dental malocclusion and improvement of facial appearance. The FACE-Q is a patient-reported outcome instrument for evaluation of surgical and psychosocial effect. The purposes of this study were to conduct a linguistic validation of all FACE-Q scales to Mandarin Chinese, to test the orthognathic surgery-related scales for reliability and validity, and to evaluate the effect of orthognathic surgery. METHODS: All FACE-Q scales and checklists were translated from English to Mandarin Chinese according to international recommendations: forward translations, backward translation, and cognitive interviews. Psychometric testing of orthognathic surgery-related scales of translated version was administered to patients with facial deformities and history of orthognathic surgery (n = 53; 17 scales) or no history of orthognathic surgery (n = 44; 11 scales), and control subjects (n = 57; 11 scales). RESULTS: All FACE-Q scales and checklists were linguistically validated into Mandarin Chinese. The contents were confirmed valid among Mandarin Chinese-speaking population. The FACE-Q scales had excellent internal consistency (Cronbach's alpha >0.70) and discriminated (p < 0.05) well between patients before and after orthognathic surgeries and normal subjects. CONCLUSIONS: This study discovered significant benefit of orthognathic surgery on improving facial appearance and psychosocial function, as compared with the non-surgical patients and normal controls.

The Impacts of Orthognathic Surgery on the Facial Appearance and Age Perception of Patients Presenting Skeletal Class III Deformity: An Outcome Study Using the FACE-Q Report and Surgical Professional-Based Panel Assessment.

BACKGROUND: A recent artificial intelligence-based investigation has shown the impacts of orthognathic surgery on the patient's facial appearance and apparent age. However, appearance and age perception as reported by patients and surgical professionals have not been addressed in the same cohort to date. METHODS: FACE-Q facial appraisal (appearance and age) and quality-of-life scale scores obtained before and after orthognathic surgery, in addition to three-dimensional photographs of 70 patients with skeletal class III deformity, were collected for a comparative cross-sectional study. Seven blinded plastic surgeons rated all photographs for apparent facial aesthetic and age scales. The FACE-Q data from 57 matched normal individuals were adopted for the comparative analyses. The correlation between the FACE-Q and the professional-based scales was tested. RESULTS: Pre-orthognathic surgery versus post-orthognathic surgery comparisons showed significant differences (p < 0.001) for all FACE-Q scales and panel assessments, with higher (FACE-Q scales and professional-based aesthetic parameters) and lower (FACE-Q patient-perceived age scale and professional-based age parameter) values for post-orthognathic surgery measurements. Patients had significantly (p < 0.001) higher (patient-perceived age scale) and lower (facial appraisal and quality-of-life scales) FACE-Q values than normal individuals for pre-orthognathic surgery but not for post-orthognathic surgery measurements. The FACE-Q facial appearance overall scale had significant correlations (p < 0.001) with the panel assessment for the parameters "beautiful" and "attractive" but not for the "pleasant" parameter. No significant correlations were observed for facial age scales. CONCLUSION: This study contributes to the orthognathic surgery literature by revealing that orthognathic surgery positively impacts the perception of apparent facial age and improves facial appearance and quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Simple Technique for the Placement of Seprafilm, a Sodium Hyaluronate or Carboxymethylcellulose Absorbable Barrier, during Laparoscopic Myomectomy.

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe.

Office Hysteroscopy as a Valid Tool for Diagnosis of Genital Tract Lesions in Females with Intact Hymen.

BACKGROUND: To evaluate the feasibility and applicability of using office hysteroscopy in women with intact hymen. METHODS: We recruited 836 patients with intact hymen with different indications who underwent diagnostic hysteroscopy without anesthesia in an outpatient setting from 2007 to 2016 at Chang Gung Memorial Hospital at Linkou. RESULTS: Patients' mean age was 35 ± 10.6 years (range 3-69 years). Most patients (86.4%) with postmenopausal bleeding had intrauterine lesions, and they were especially at high risk (50%) for endometrial hyperplasia or malignancy. Five hundred thirty (63.3%) patients had histologic findings confirming concordance between hysteroscopic and histologic findings. Submucosal myoma had the highest concordance (96.3%), whereas endometrial hyperplasia had the lowest concordance (50%). Forty-eight patients (5.7%) had endometrial hyperplasia, and 35 patients (4.2%) had endometrial malignancy. Two patients who were thought to have nonspecific endometrial thickening actually had endometrial pathology. CONCLUSIONS: Hysteroscopy through vaginoscopic approach is feasible and well-tolerated in the patients with intact hymen. This outpatient procedure provides accurate evaluation of lesions of the genital tract and should be considered in patients without a history of intercourse.

Renin-angiotensin system activation and imbalance of matrix metalloproteinase-9/tissue inhibitor of matrix metalloproteinase-1 in cold-induced stroke.

AIMS: In the present study, we investigated the roles of renin-angiotensin system (RAS) activation and imbalance of matrix metalloproteinase-9 (MMP-9)/tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) in cold-induced stroke during chronic hypertension, as well as the protective effects of captopril and recombinant human TIMP-1 (rhTIMP-1). MAIN METHODS: Rats were randomly assigned to sham; 2-kidney, 2-clip (2K-2C); 2K-2C + captopril, and 2K-2C + rhTIMP-1 groups. After blood pressure values had stabilized, each group was randomly divided into an acute cold exposure (ACE) group (12-h light at 22 °C/12-h dark at 4 °C) and a non-acute cold exposure (NACE) group (12-h light/12-h dark at 22 °C), each of which underwent three cycles of exposure. Captopril treatment was administered via gavage (50 mg/kg/d), while rhTIMP-1 treatment was administered via the tail vein (60 µg/kg/36 h). KEY FINDINGS: In the 2K-2C group, angiotensin II (AngII) and MMP-9 levels increased in both the plasma and cortex, while no such changes in TIMP-1 expression were observed. Cold exposure further upregulated AngII and MMP-9 levels and increased stroke incidence. Captopril and rhTIMP-1 treatment inhibited MMP-9 expression and activation and decreased stroke incidence in response to cold exposure. SIGNIFICANCE: The present study is the first to demonstrate that cold exposure exacerbates imbalance between MMP-9 and TIMP-1 by activating the RAS, which may be critical in the initiation of stroke during chronic hypertension. In addition, our results suggest that captopril and rhTIMP-1 exert protective effects against cold-induced stroke by ameliorating MMP-9/TIMP-1 imbalance.

Facial Appearance and Psychosocial Features in Orthognathic Surgery: A FACE-Q- and 3D Facial Image-Based Comparative Study of Patient-, Clinician-, and Lay-Observer-Reported Outcomes.

Outcome measures reported by patients, clinicians, and lay-observers can help to tailor treatment plans to meet patients' needs. This study evaluated orthognathic surgery (OGS) outcomes using pre- and post-OGS patients' (n = 84) FACE-Q reports, and a three-dimensional facial photograph-based panel assessment of facial appearance and psychosocial parameters, with 96 blinded layperson and orthodontic and surgical professional raters, and verified whether there were correlations between these outcome measurement tools. Post-OGS FACE-Q and panel assessment measurements showed significant (p < 0.001) differences from pre-OGS measurements. Pre-OGS patients' FACE-Q scores were significantly (p < 0.01) lower than normal, age-, gender-, and ethnicity-matched individuals' (n = 54) FACE-Q scores, with no differences in post-OGS comparisons. The FACE-Q overall facial appearance scale had a low, statistically significant (p < 0.001) correlation to the facial-aesthetic-based panel assessment, but no correlation to the FACE-Q lower face and lips scales. No significant correlation was observed between the FACE-Q and panel assessment psychosocial-related scales. This study demonstrates that OGS treatment positively influences the facial appearance and psychosocial-related perceptions of patients, clinicians and lay observers, but that there is only a low, or no, correlation between the FACE-Q and panel assessment tools. Future investigations may consider the inclusion of both tools as OGS treatment endpoints for the improvement of patient-centered care, and guiding the health-system-related decision-making processes of multidisciplinary teams, policymakers, and other stakeholders.

Selective modification of aligned carbon nanotubes by N2 plasma and their diode behavior.

Aligned carbon nanotubes made by pyrolysis of ferrocene are selectively treated with N2 plasma at various durations. Raman spectra reveal that polar bonds form at treated regions and result in increased Raman breathing mode. XPS support Raman and verify the C-O/C-N formations in carbon lattices. Electrical measurements show an unipolar p-type character as probes are placed in contact with untreated regions of nanotubes. Reposition of probes at untreated and treated regions respectively produces a current-voltage profile that resembles a p-n junction diode with forward current reaching a value as high as 100 mA at 3 V. Ab initio calculations confirm the on-tube junction and creation of a donor state is owing to C-N formations.

Measurement of serum IgG4 levels by an established ELISA system and its clinical applications in autoimmune diseases.

IgG4-related disease (IgG4-RD) is a novel and rare autoimmune disease entity. Elevated serum IgG4 level is strongly suggestive of IgG4-RD. But it is still unknown whether serum IgG4 elevation commonly occurs in other autoimmune diseases. In this study, the serum IgG4 levels were detected by an established enzyme-linked immunosorbent assay (ELISA) in a variety of autoimmune diseases including systemic lupus erythematosus (SLE), Sjogren's syndrome (SS), polymyositis or dermatomyositis (PM/DM) and IgG4-RD. To evaluate the reliability of this ELISA system, some of our samples were sent to a lab in Kanazawa Medical University, Japan, and detected by using the nephelometric assay. The results showed that our findings were consistent with theirs. Moreover, it was found that the serum IgG4 levels were 0.23±0.16 g/L in 53 healthy controls, 0.16±0.15 g/L in 103 SLE patients, 0.22±0.18 g/L in 41 SS patients and 0.40±0.32 g/L in 21 PM/DM patients. No significant difference in the serum IgG4 level was observed among these groups (P>0.05). The serum IgG4 levels of two cases of IgG4-RD were 1.63 and 4.65 g/L respectively, and both decreased markedly after treatment with glucocorticoids. These data indicated that this established ELISA system can be used for detecting serum IgG4 levels. Elevated serum IgG4 levels help diagnose IgG4-RD and evaluate the curative effect of this condition rather than other autoimmune diseases.