Associating genital hiatus size with long-term outcomes after apical suspension.

INTRODUCTION AND HYPOTHESIS: To describe associations between postoperative genital hiatus (GH) measurements and long-term anatomical and subjective outcomes following pelvic reconstructive surgery involving apical suspension. METHODS: This IRB-approved secondary analysis reports outcomes 3-7 years following robotic sacrocolpopexy (RSC) and uterosacral ligament suspension (USLS). Objective and subjective measures were obtained through clinical examinations and validated questionnaires. Subjective success was defined as the absence of a symptomatic bulge or retreatment. Objective success was defined as all Pelvic Organ Prolapse Quantification (POP-Q) points at or above -1 at the long-term examination. Postoperative GH measures were obtained at 6 weeks (early) and 3-7 years (long term) postoperatively. GH measurements were classified as either normal (<4 cm) or wide (≥4 cm). Logistic regression identified associations between postoperative GH measurements and long-term subjective and objective outcomes. RESULTS: A total of 154 subjects completed long-term POP-Q examinations (74 RSC and 80 USLS). The median time to follow-up (minimum, maximum) was 59 months (range 34-89); 97.4% were Caucasian. Subjective success was achieved in 134 (87%), and objective success in 139 (90.2%) subjects. The majority (79%) underwent a posterior repair during their index surgery. An early postoperative GH of less than 4 cm was associated with an 11-fold higher likelihood of subsequent objective success (11.8, 2.7-51.7; p = 0.001). Furthermore, a postoperative GH less than 4 cm was not associated with dyspareunia at long-term follow-up. CONCLUSIONS: Early postoperative GH <4 cm was associated with superior long-term objective success, without increasing dyspareunia. These data support correcting GH to <4 cm during prolapse repair with apical suspension to reduce objective long-term failure.

Liposomal bupivacaine decreases pain following retropubic sling placement: a randomized placebo-controlled trial.

BACKGROUND: Midurethral slings are commonly used to treat stress urinary incontinence. Pain control, however, may be a concern. Liposomal bupivacaine is a local anesthetic with slow release over 72 hours, demonstrated to lower pain scores and decrease narcotic use postoperatively. OBJECTIVE: The purpose of this study was to examine the impact of liposomal bupivacaine on pain scores and narcotic consumption following retropubic midurethral sling placement. STUDY DESIGN: This randomized, placebo-controlled trial enrolled women undergoing retropubic midurethral sling procedures with or without concomitant anterior or urethrocele repair. Subjects were allocated to receive liposomal bupivacaine (intervention) or normal saline placebo injected into the trocar paths and vaginal incision at the conclusion of the procedure. At the time of drug administration, surgeons became unblinded, but did not collect outcome data. Participants remained blinded to treatment. Surgical procedures and perioperative care were standardized. The primary outcome was the visual analog scale pain score 4 hours after discharge home. Secondary outcomes included narcotic consumption, time to first bowel movement, and pain scores collected in the mornings and evenings until postoperative day 6. The morning pain item assessed "current level of pain"; the evening items queried "current level of pain," "most intense pain today," "average pain today with activity," and "average pain today with rest." Likert scales were used to measure satisfaction with pain control at 1- and 2-week postoperative intervals. Sample size calculation deemed 52 subjects per arm necessary to detect a mean difference of 10 mm on a 100-mm visual analog scale. To account for 10% drop out, 114 participants were needed. RESULTS: One hundred fourteen women were enrolled. After 5 exclusions, 109 cases were analyzed: 54 women received intervention, and 55 women received placebo. Mean participant age was 52 years, and mean body mass index was 30.4 kg/m2. Surgical and demographic characteristics were similar, except for a slightly higher body mass index in the placebo group (31.6 vs 29.2 kg/m2; P=.050), and fewer placebo arm subjects received midazolam during anesthesia induction (44 vs 52; P=.015). For the primary outcome, pain score (millimeter) 4 hours after discharge home was lower in the intervention group (3.5 vs 13.0 millimeters; P=.014). Pain scores were also lower for subjects receiving liposomal bupivacaine at other time points collected during the first three postoperative days. Furthermore, fewer subjects in the intervention group consumed narcotic medication on postoperative day 2 (12 vs 27; P=.006). There was no difference in satisfaction with pain control between groups. Side-effects experienced, rate of postoperative urinary retention, and time to first bowel movement were similar between groups. Finally, no serious adverse events were noted. CONCLUSION: Liposomal bupivacaine decreased postoperative pain scores following retropubic midurethral sling placement, though pain was low in both the intervention and placebo groups. Participants who received liposomal bupivacaine were less likely to use narcotics on postoperative day 2. For this common outpatient surgery, liposomal bupivacaine may be a beneficial addition. Given the cost of this intervention, however, future cost-effective analyses may be useful.

M.mode.ify: A Free Online Tool to Generate Post Hoc M-Mode Images From Any Ultrasound Clip.

We present a software tool designed to generate an M-mode image post hoc from any B-mode ultrasound clip, along any possible axis. M.mode.ify works by breaking down an ultrasound clip into individual frames. It then rotates and crops these frames by using a user-selected M-mode line. The post hoc M-mode image is created by splicing these frames together. Users can measure time and distance after proper calibration through the M.mode.ify interface. This tool opens up new possibilities for clinical application, quality assurance, and research. It is available free for public use at http://www.ultrasoundoftheweek.com/M.mode.ify/.

Distinct Ecological Niche of Anal, Oral, and Cervical Mucosal Microbiomes in Adolescent Women.

Human body sites represent ecological niches for microorganisms, each providing variations in microbial exposure, nutrient availability, microbial competition, and host immunological responses. In this study, we investigated the oral, anal, and cervical microbiomes from the same 20 sexually active adolescent females, using culture-independent, next-generation sequencing. DNA from each sample was amplified for the bacterial 16S rRNA gene and sequenced on an Illumina platform using paired-end reads. Across the three anatomical niches, we found significant differences in bacterial community composition and diversity. Overall anal samples were dominated with Prevotella and Bacteriodes, oral samples with Streptococcus and Prevotella, and cervical samples with Lactobacillus. The microbiomes of a few cervical samples clustered with anal samples in weighted principal coordinate analyses, due in part to a higher proportion of Prevotella in those samples. Additionally, cervical samples had the lowest alpha diversity. Our results demonstrate the occurrence of distinct microbial communities across body sites within the same individual.

Double cervix: clarifying a diagnostic dilemma.

OBJECTIVE: Although double cervix is often considered to indicate uterus didelphys, it may be challenging to determine the true associated anomaly as double cervix occurs with other müllerian anomalies. Our purpose is to report the frequency of uterine müllerian anomalies that occur with a double cervix and identify imaging or clinical criteria to help classify the associated anomaly. STUDY DESIGN: After institutional review board approval, an electronic search was performed to identify patients with double cervix and pelvic magnetic resonance imaging (MRI) between 1976-2010 (using International Statistical Classification of Diseases and Related Health Problems, Edition 9 and Hospital International Classification of Diseases Adapted codes). MRIs were reviewed to classify the müllerian anomaly. Clinical characteristics including cervical canal thickness, intercervical distance and orientation were recorded. Kruskal-Wallis and χ(2) tests were used to test for differences in patient and imaging characteristics across müllerian anomalies. RESULTS: There were 64 patients who met inclusion criteria: 32 (50%) septate uterus, 27 (42%) uterus didelphys and 5 (8%) bicornuate uterus. Cervical canal divergence was present in 34% (11/32) with septate uterus, 26% (7/27) with uterus didelphys, and none with bicornuate uterus. Mean intercervical distance was significantly greater (P < .001) in uterus didelphys (12.05 mm) compared with septate (5.43 mm) or bicornuate uterus (5.40 mm). CONCLUSION: Septate uterus is as common as uterus didelphys, and considerably more common than bicornuate uterus, in women with a double cervix. Although a widened intercervical distance may support the MRI diagnosis of uterus didelphys, careful evaluation of the uterine fundus is required for correct diagnosis when encountering a double cervix.

Anesthetic implications for patients with Swyer-James syndrome.

OBJECTIVE: The aim of this study was to describe the anesthetic management and perioperative outcomes in patients with Swyer-James syndrome (SJS), a rare acquired pulmonary disorder caused by postinfectious bronchiolitis obliterans resulting in airway obstruction and focal areas of emphysema or bronchiectasis. DESIGN: A retrospective computerized search of the medical records database at a large academic tertiary referral center was performed for patients with SJS from January 1, 2001 through July 31, 2012 who underwent procedures requiring anesthesia. A review of the perioperative course in the SJS patients as well as in those identified by a literature search was performed. SETTING: Academic tertiary referral center, both inpatient and outpatient settings. PARTICIPANTS: Patients with a diagnosis of SJS. INTERVENTIONS: No interventions were performed. MEASUREMENTS AND MAIN RESULTS: The authors identified 4 patients with SJS who underwent 7 uneventful anesthetics including one lung resection. Three patients were symptomatic preoperatively. The literature review identified 23 SJS patients who underwent lung resection for recurrent pulmonary symptoms. One patient developed hypoxemia during one-lung ventilation. Three patients had a prolonged hospital stay (≥10 days). All patients undergoing lung resection were young (≤42 years of age). CONCLUSION: Though SJS may be an incidental finding, these patients may have marked symptomatology, recurrent pulmonary infections, and pneumothoraces that may require lung resection. The patients tolerated anesthesia well. In severe SJS cases, pulmonary pathology and perioperative management strategies parallel that of patients with severe obstructive pulmonary disease.

1H, 13C, and 15N resonance assignments of the La Motif of the human La-related protein 1.

Human La-related protein 1 (HsLARP1) is involved in post-transcriptional regulation of certain 5' terminal oligopyrimidine (5'TOP) mRNAs as well as other mRNAs and binds to both the 5'TOP motif and the 3'-poly(A) tail of certain mRNAs. HsLARP1 is heavily involved in cell proliferation, cell cycle defects, and cancer, where HsLARP1 is significantly upregulated in malignant cells and tissues. Like all LARPs, HsLARP1 contains a folded RNA binding domain, the La motif (LaM). Our current understanding of post-transcriptional regulation that emanates from the intricate molecular framework of HsLARP1 is currently limited to small snapshots, obfuscating our understanding of the full picture on HsLARP1 functionality in post-transcriptional events. Here, we present the nearly complete resonance assignment of the LaM of HsLARP1, providing a significant platform for future NMR spectroscopic studies.

NMR Resonance Assignment of the LA Motif of Human LA-Related Protein 1.

Human La-related protein 1 (HsLARP1) is involved in post-transcriptional regulation of certain 5' s terminal oligopyrimidine (5'TOP) mRNAs as well as other mRNAs and binds to both the 5'TOP motif and the 3'-poly(A) tail of certain mRNAs. HsLARP1 is heavily involved in cell proliferation, cell cycle defects, and cancer, where HsLARP1 is significantly upregulated in malignant cells and tissues. Like all LARPs, HsLARP1 contains a folded RNA binding domain, the La motif (LaM). Our current understanding of post-transcriptional regulation that emanates from the intricate molecular framework of HsLARP1 is currently limited to small snapshots, obfuscating our understanding of the full picture on HsLARP1 functionality in post-transcriptional events. Here, we present the nearly complete resonance assignment of the LaM of HsLARP1, providing a significant platform for future NMR spectroscopic studies.

Effect of resistance training during hemodialysis on circulating cytokines: a randomized controlled trial.

The purpose of this study was to evaluate the effect of a 12-week intradialytic progressive resistance training (PRT) regimen on circulating pro- and anti-inflammatory cytokines. Forty-nine patients (62.6 ± 14.2 years) were recruited from the outpatient hemodialysis unit of the St. George Public Hospital, Sydney, Australia. Patients were randomized to: PRT + usual care (n = 24) or usual care control (n = 25). The PRT group performed two sets of 10 exercises at high intensity using free-weights, 3 times per week for 12 weeks during dialysis, while the control group did not exercise. Tumor necrosis factor-alpha, interleukin-1b, interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10, and interleukin-12 were measured in serum before and after the intervention period. Muscle cross-sectional area (CSA), intramuscular lipid, intermuscular adipose tissue, and subcutaneous and total thigh fat, evaluated via computed tomography of the non-dominant mid-thigh, were also collected at both time points. All cytokines were significantly elevated in the total cohort at baseline compared with normative data. There were no cytokine changes over time or between groups (p > 0.05). In secondary analyses pooling the groups, changes in logIL-6 and IL-8 were inversely related to changes subcutaneous thigh fat (p < 0.05) while changes in logIL-6 were also inversely related to changes in thigh muscle CSA, and total thigh fat (p < 0.03). These data suggest that 12 weeks of intradialytic progressive resistance training does not improve circulating pro- and anti-inflammatory markers. Further research is required to elucidate the implications and mechanisms of the relationships between IL-6 and IL-8 and body composition in ESRD.

Thermochemical ablation in an ex-vivo porcine liver model using acetic acid and sodium hydroxide: proof of concept.

PURPOSE: To establish proof of concept in tissue, using the exothermic neutralization reaction of acetic acid and sodium hydroxide in ex vivo porcine liver and to conduct an initial probe into the relationships of volume and concentration of reagents to temperatures and the areas affected. MATERIALS AND METHODS: A total of 0.5 mL or 2 mL of either 5 mole/L or 10 mole/L acid and base solutions was injected simultaneously into the periphery of ex vivo porcine liver using a prototype injection device. Tissue temperature was recorded at the injection site for 5 minutes using a type T thermocouple temperature probe inserted parallel to and near the tip of the injection device. The injections were repeated for infrared thermography, and ablated tissues were sectioned quickly and imaged. A gross photograph was captured in each case to provide correlation. RESULTS: Maximum temperatures (17°C baseline) ranged from 42.1° ± α3.34°C to 61.7° ± α10°C (P<.05) when injecting 0.5 mL of 5 mole/L reactants and 2 mL of 10 mole/L reactants, respectively. The maximum temperature measured by infrared imaging ranged from 31°-47°C. Using an infrared viewing scale from 19°-40°C, the cross-sectional area of tissue heating above baseline measured from 1.07 cm(2)± 0.45 to 4.95 cm(2)± 0.28 (P <05). CONCLUSIONS: The reaction of acetic acid and sodium hydroxide releases significant heat energy at the site of injection, and histologic changes are consistent with coagulation necrosis. Increased reagent concentration and volume were associated with larger temperature changes and larger areas of hyperthermia at gross pathology and infrared imaging.

In vitro thermal profile suitability assessment of acids and bases for thermochemical ablation: underlying principles.

PURPOSE: To measure and compare temperature changes in a recently developed gel phantom for thermochemical ablation as a function of reagent strength and concentration with several acids and bases. MATERIALS AND METHODS: Aliquots (0.5-1 mL) of hydrochloric acid or acetic acid and sodium hydroxide or aqueous ammonia were injected for 5 seconds into a hydrophobic gel phantom. Stepwise increments in concentration were used to survey the temperature changes caused by these reactions. Injections were performed in triplicate, measured with a thermocouple probe, and plotted as functions of concentration and time. RESULTS: Maximum temperatures were reached almost immediately in all cases, reaching 75 degrees C-110 degrees C at the higher concentrations. The highest temperatures were seen with hydrochloric acid and either base. More concentrated solutions of sodium hydroxide tended to mix incompletely, such that experiments at 9 M and higher were difficult to perform consistently. CONCLUSIONS: Higher concentrations for any reagent resulted in higher temperatures. Stronger acid and base combinations resulted in higher temperatures versus weak acid and base combinations at the same concentration. Maximum temperatures obtained are in a range known to cause tissue coagulation, and all combinations tested therefore appeared suitable for further investigation in thermochemical ablation. Because of the loss of the reaction chamber shape at higher concentrations of stronger agents, the phantom does not allow complete characterization under these circumstances. Adequate mixing of reagents to maximize heating potential and avoid systemic exposure to unreacted acid and base must be addressed if the method is to be safely employed in tissues. In addition, understanding factors that control lesion shape in a more realistic tissue model will be critical.

Uterosacral Ligament Suspension: A Radiographic Study of Suture Location in Live Subjects.

OBJECTIVES: This study aimed to describe uterosacral ligament suspension (USLS) suture location relative to the surrounding anatomy in a living model using computed tomographic imaging. METHODS: This was an institutional review board-approved prospective descriptive study. Women aged 18 to 85 years undergoing vaginal hysterectomy with USLS were eligible. A size 'small' titanium vascular clip was applied to the base of each USLS suture. Computed tomography of the pelvis was performed on postoperative day 1. Preoperative and postoperative neurologic questionnaires and physical examinations were performed. A sample size of 15 subjects was deemed appropriate for this pilot study. RESULTS: Seventeen subjects were enrolled: 2 excluded and 15 analyzed. The median (interquartile range) age of the subjects was 57 (22) years. The closest branch of the internal iliac complex was 2.6 (0.9) cm (median [interquartile range]) from the proximal suture on the right and 2.6 (0.5) cm on the left. The right ureter was 2.1 (0.7) cm from the right proximal suture. The left ureter was 2.3 (1.0) cm from the left proximal suture. The rectal lumen were 3.0 (1.6) cm from the right proximal suture and 2.8 (1.4) cm from the left proximal suture. No subjects were found to have neurologic involvement of the sutures based on neurologic questionnaire responses and physical examination. CONCLUSIONS: In live subjects, our study confirms that the vasculature, ureter, and rectum of the pelvic side wall are near suture placement for USLS. This information highlights the importance of careful dissection and awareness of anatomic landmarks.

Odorant Receptor Inhibition Is Fundamental to Odor Encoding.

Most natural odors are complex mixtures of volatile components, competing to bind odorant receptors (ORs) expressed in olfactory sensory neurons (OSNs) of the nose. To date, surprisingly little is known about how OR antagonism shapes neuronal representations in the detection layer of the olfactory system. Here, we investigated its prevalence, the degree to which it disrupts OR ensemble activity, and its conservation across phylogenetically related ORs. Calcium imaging microscopy of dissociated OSNs revealed significant inhibition, often complete attenuation, of responses to indole-a commonly occurring volatile associated with both floral and fecal odors-by a set of 36 tested odorants. To confirm an OR mechanism for the observed inhibition, we performed single-cell transcriptomics on OSNs exhibiting specific response profiles to a diagnostic panel of odorants and identified three paralogous receptors-Olfr740, Olfr741, and Olfr743-which, when tested in vitro, recapitulated OSN responses. We screened ten ORs from the Olfr740 gene family with ∼800 perfumery-related odorants spanning a range of chemical scaffolds and functional groups. Over half of these compounds (430) antagonized at least one of the ten ORs. OR activity fitted a mathematical model of competitive receptor binding and suggests normalization of OSN ensemble responses to odorant mixtures is the rule rather than the exception. In summary, we observed OR antagonism occurred frequently and in a combinatorial manner. Thus, extensive receptor-mediated computation of mixture information appears to occur in the olfactory epithelium prior to transmission of odor information to the olfactory bulb.

Pilot-Scale Assessment of a Novel Farrowing Creep Area Supplementary Heat Source.

Pre-weaning morality (PWM) is attributed to a poor creep area microclimate and causes major economic and productivity losses for the US swine industry. Piglets need supplementary heat to overcome a high surface area to body weight ratio and minimal thermoregulation. A pilot-scale study was conducted to evaluate a semi-enclosed heated microclimate (SEHM) as a supplementary heat source for farrowing creep areas over six farrowing cycles (from January to July 2019) in two rooms with 24 farrowing stalls in each room. Six SEHMs (each SEHM covers two stalls) were randomly distributed to each room and compared to heat lamps (HLs) for productivity and electricity usage. Data from 113 (SEHM) and 101 litters (HL) showed no significant difference between treatments in average daily gain (p = 0.26), 252.4 ± 8.0 g hd-1 d-1 (SEHM) and 260.3 ± 8.1 g hd-1 d-1 (HL) and PWM (p = 0.08), 9.67% ± 0.82% (SEHM) and 12.04% ± 0.87% (HL). However, a significant difference (p = 0.02) was noted in the PWM attributed to over-lay mortalities, 4.05% ± 0.76% (SEHM) compared to 6.04% ± 0.78% (HL). The SEHM electricity averaged 3.25 kWh d-1 (2.91, 3.59 kWh d-1; 95% CI), which was significantly different (p < 0.01) from the HL equivalent (125 W bulb; 6 kWh d-1).

Uterosacral Ligament Suspension Versus Robotic Sacrocolpopexy for Treatment of Apical Pelvic Organ Prolapse.

OBJECTIVE: The aim of the study was to compare long-term outcomes of uterosacral ligament suspension (USLS) versus robotic sacrocolpopexy (RSC) in patients with pelvic organ prolapse. METHODS: This was an institutional review board-approved retrospective cohort study. Women 3 to 7 years after USLS or RSC were contacted for enrollment. Participants were asked to complete validated questionnaires and physical examinations. The primary outcomes were no symptoms of bulge or retreatment for prolapse (subjective) and POP-Q examination demonstrating prolapse above or equal to -1 (objective). For the subjective outcome, a noninferiority calculation with 10% noninferiority margin deemed 91 subjects in each group were required. RESULTS: We identified the following 770 eligible subjects: 205 were contacted, 19 declined, 186 subjects agreed to participate, and 2 were excluded. There were 92 subjects per group in the analysis for the primary subjective outcome, and 84% underwent examinations for the objective outcome. Baseline characteristics were overall similar; however, previous prolapse surgery was more common in the RSC group (P < 0.001). Subjective success was achieved in 83 subjects in the USLS group and 78 subjects in the RSC group (90.2% vs 84.4%, respectively, P = 0.265 [95% confidence interval = -0.036 to 1.000]). Objective success was noted in 93.2% and 91.3% of the USLS and RSC groups, respectively (P = 0.869). Postoperative complication rates were low and did not differ between groups. Mesh complications were noted in 6.6% of the RSC group. One subject in the USLS group reported pain related to surgery. CONCLUSION: Uterosacral ligament suspension was noninferior to RSC at 3- to 7-year postsurgery for subjective symptoms and similar for objective outcomes. Both approaches showed high success rates and strong patient satisfaction.

Regional economic impact assessment: Evaluating remedial alternatives for the Portland Harbor Superfund Site, Portland, Oregon, USA.

The present paper describes a methodology for evaluating impacts of Superfund remedial alternatives on the regional economy in the context of a broader sustainability evaluation. Although economic impact methodology is well established, some applications to Superfund remedial evaluation have created confusion because of seemingly contradictory results. This confusion arises from failure to be explicit about 2 opposing impacts of remediation expenditures: 1) positive regional impacts of spending additional money in the region and 2) negative regional impacts of the need to pay for the expenditures (and thus forgo other expenditures in the region). The present paper provides a template for economic impact assessment that takes both positive and negative impacts into account, thus providing comprehensive estimates of net impacts. The paper also provides a strategy for identifying and estimating major uncertainties in the net impacts. The recommended methodology was applied at the Portland Harbor Superfund Site, located along the Lower Willamette River in Portland, Oregon, USA. The US Environmental Protection Agency (USEPA) developed remedial alternatives that it estimated would cost up to several billion dollars, with construction durations possibly lasting decades. The economic study estimated regional economic impacts-measured in terms of gross regional product (GRP), personal income, population, and employment-for 5 of the USEPA alternatives relative to the "no further action" alternative. Integr Environ Assess Manag 2018;14:32-42. © 2017 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).