Endometriosis-Related Chronic Pelvic Pain.

Endometriosis, which is the presence of endometrial stroma and glands outside the uterus, is one of the most frequently diagnosed gynecologic diseases in reproductive women. Patients with endometriosis suffer from various pain symptoms such as dysmenorrhea, dyspareunia, and chronic pelvic pain. The pathophysiology for chronic pain in patients with endometriosis has not been fully understood. Altered inflammatory responses have been shown to contribute to pain symptoms. Increased secretion of cytokines, angiogenic factors, and nerve growth factors has been suggested to increase pain. Also, altered distribution of nerve fibers may also contribute to chronic pain. Aside from local contributing factors, sensitization of the nervous system is also important in understanding persistent pain in endometriosis. Peripheral sensitization as well as central sensitization have been identified in patients with endometriosis. These sensitizations of the nervous system can also explain increased incidence of comorbidities related to pain such as irritable bowel disease, bladder pain syndrome, and vulvodynia in patients with endometriosis. In conclusion, there are various possible mechanisms behind pain in patients with endometriosis, and understanding these mechanisms can help clinicians understand the nature of the pain symptoms and decide on treatments for endometriosis-related pain symptoms.

The efficacy of gonadotropin-releasing hormone agonist treatment before hysteroscopic myomectomy for large-sized submucosal leiomyoma.

To evaluate the efficacy and safety of a gonadotropin-releasing hormone (GnRH) agonist for treating large-sized submucosal leiomyoma before hysteroscopic myomectomy. The data were retrospectively collected from patients who underwent a hysteroscopic myomectomy for a submucosal leiomyoma >3.5 cm in size from January 2009 to December 2018. The patients were divided into the GnRH group and the control group according to whether they were pretreated before surgery. A total of 61 patients were included in the study, 31 in the GnRH agonist group and 30 in the control group. At diagnosis, the maximum leiomyoma diameter was similar between the 2 groups (4.67 ± 0.6 cm in the GnRH agonist group vs 3.82 ± 0.6 cm in the control group, P = .061). After pretreatment with the GnRH agonist, the maximum diameter was significantly smaller in the GnRH agonist group compared to the control group (3.82 ± 0.6 vs 4.33 ± 0.8 cm, respectively, P = .004). The leiomyoma volume in the GnRH agonist group decreased by 55.6%, from 41.68 ± 15.7 to 23.19 ± 10.4 cm3, which led to significant differences in leiomyoma volume between the 2 groups (23.19 ± 10.4 cm3 in the GnRH agonist group vs 33.22 ± 24.7 cm3 in the control group, P = .042). The GnRH agonist group showed a shorter operation time (37.7 vs 43.9 minutes, P = .040) and less uterine distention media was used (6800 vs 9373.3 mL, P = .037) compared to the control group. Postoperative complications such as estimated blood loss, remnant leiomyoma, and recurrence were similar between the 2 groups. Treatment with a GnRH agonist before hysteroscopic myomectomy for large submucosal leiomyoma might decrease the volume of the leiomyoma, reduce operation time, and the amount of uterine-distension media used without surgical complications.

Successful delayed delivery of the second twin by evacuating the cord prolapsed first fetus and emergent cerclage: a report of 2 cases.

BACKGROUND: In twin pregnancies, the cord prolapse of either fetus during the pre-viable period leads to fetal death but can also cause an intrauterine infection, leading to death or prematu-re birth of the remaining fetus. However, there are no validated protocols to prolong the gestational period or decrease the morbidity and mortality of the remaining fetus. CASE PRESENTATION: The present cases were PPROM and cord prolapse very early during the second trimester (around 17 weeks in the first case and 19 weeks in the second case). The first fetus was evacuated, and cervical cerclage was performed at 23 and 20 weeks in the two cases, respectively. After maintaining the pregnancy, the second baby was born around 27 and 39 weeks in the first and second cases, respectively. The delivery interval between the first and second fetuses was 46 days in the first case and 126 days in the second case. CONCLUSION: If cord prolapse is identified at a pre-viable time in twin fetuses, evacuation and cerclage should be performed as soon as possible after the cord prolapse to reduce intrauterine infection and increase the survival chances of the remaining fetus.

Effect of rhBMP-2 applied with a 3D-printed titanium implant on new bone formation in rabbit calvarium.

OBJECTIVE: This study sought to compare the biocompatibility of a three-dimensional (3D)-printed titanium implant with a conventional machined titanium product, as well as the effect of such implant applied with recombinant human Bone Morphogenetic Protein Type 2 (rhBMP-2) for guided bone regeneration. METHODOLOGY: Disk-shaped titanium specimens fabricated either by the conventional machining technique or by the 3D-printing technique were compared by MC3T3-E1 cells cytotoxicity assay. New bone formation was evaluated using a rapid prototype titanium cap applied to the calvaria of 10 rabbits, which were divided into two groups: one including an atelopeptide collagen plug on one side of the cap (group I) and the other including a plug with rhBMP-2 on the other side (group II). At six and 12 weeks after euthanasia, rabbits calvaria underwent morphometric analysis through radiological and histological examination. RESULTS: Through the cytotoxicity assay, we identified a significantly higher number of MC3T3-E1 cells in the 3D-printed specimen when compared to the machined specimen after 48 hours of culture. Moreover, morphometric analysis indicated significantly greater bone formation at week 12 on the side where rhBMP-2 was applied when evaluating the upper portion immediately below the cap. CONCLUSION: The results suggest that 3D-printed titanium implant applied with rhBMP-2 enables new bone formation.

Client-Centered Breastfeeding-Promotion Strategies: Q Methodology.

Fewer Korean women are choosing the 6 months of exclusive breastfeeding that are recommended for obtaining its maximal benefits despite an increasing effort to promote breastfeeding. Successful breastfeeding education and counseling need to be segmentally designed on the basis of client characteristics. This study explored the perceptions of breastfeeding in pregnant and 6 month postpartum Korean women using the Q methodology, a useful research approach to examine personal perceptions, feelings, and values about a concept or phenomenon of interest and identify typologies of perspectives. The Q sample consisted of 38 statements representing the universe of viewpoints on breastfeeding. The P sample (N = 49) included women who shared their perceptions of breastfeeding and filled each grid with a statement in the Q sorting table. Data were analyzed using the PC-QUANL program. Varimax (orthogonal) rotation revealed four factors that explained 53.0% of variance: maternal privilege (Factor 1), option based on emotion (Factor 2), option if efficient (Factor 3), and option if I have sufficient problem-solving skills (Factor 4). Korean women have changed their attitudes toward breastfeeding, with all participants viewing breastfeeding as optional. Breastfeeding-promotion campaigns and education need to consider societal norms and changes in women's beliefs and perceptions.

Effect of rhBMP-2 applied with a 3D-printed titanium implant on new bone formation in rabbit calvarium

Abstract Objective This study sought to compare the biocompatibility of a three-dimensional (3D)-printed titanium implant with a conventional machined titanium product, as well as the effect of such implant applied with recombinant human Bone Morphogenetic Protein Type 2 (rhBMP-2) for guided bone regeneration. Methodology Disk-shaped titanium specimens fabricated either by the conventional machining technique or by the 3D-printing technique were compared by MC3T3-E1 cells cytotoxicity assay. New bone formation was evaluated using a rapid prototype titanium cap applied to the calvaria of 10 rabbits, which were divided into two groups: one including an atelopeptide collagen plug on one side of the cap (group I) and the other including a plug with rhBMP-2 on the other side (group II). At six and 12 weeks after euthanasia, rabbits calvaria underwent morphometric analysis through radiological and histological examination. Results Through the cytotoxicity assay, we identified a significantly higher number of MC3T3-E1 cells in the 3D-printed specimen when compared to the machined specimen after 48 hours of culture. Moreover, morphometric analysis indicated significantly greater bone formation at week 12 on the side where rhBMP-2 was applied when evaluating the upper portion immediately below the cap. Conclusion The results suggest that 3D-printed titanium implant applied with rhBMP-2 enables new bone formation.

Distribution of lymphocele following lymphadenectomy in patients with gynecological malignancies.

OBJECTIVE: This study identified the distribution of lymphocele, as well as the factors associated with lymphocele formation, in patients undergoing pelvic and/or para-aortic lymph node dissection (PLND and/or PALND) for gynecologic malignancies. METHODS: This study was retrospective, and data were collected from patients who underwent surgical procedures including lymphadenectomy due to gynecologic malignancies from March 2013 to May 2016. Lymphocele was defined by postoperative computer tomography within 2 weeks after surgery. RESULTS: A total of 116 patients underwent lymphadenectomy, of whom, 47 (42.0%) developed lymphocele and 14 (12.1%) had symptomatic lymphocele formation. The affecting factors of lymphocele formation were PLND concomitant with PALND and a large amount of blood loss ≥600 mL (P=0.030 and P=0.006, respectively). All clinical factors were not significantly different between patients with symptomatic and asymptomatic lymphocele. Lymphocele developed more frequently in the left side (67.1%) of the body compared to the right side (48.7%), and in the pelvic area (75.9%) compared to the para-aortic area (24.1%, P<0.001, both). CONCLUSION: Lymphocele formation is more prevalent in the left and pelvic area of the body compared to the right and paraaortic side. PLND concurrent with PALND and large amounts of blood loss were significant risk factors for lymphocele formation.

A retrospective clinical investigation for the effectiveness of closed reduction on nasal bone fracture.

BACKGROUND: The nasal bone is the most protruding bony structure of the facial bones. Nasal bone fracture is the most common facial bone fracture. The high rate of incidence of nasal bone fracture emphasizes the need for systematical investigation of epidemiology, surgical techniques, and complications after surgery. The objective of this study is to investigate the current trends in the treatment of nasal bone fractures and the effectiveness of closed reduction depending on the severity of the nasal bone fracture. PATIENTS AND METHODS: A total of 179 patients with a nasal bone fracture from 2009 to 2017 were enrolled. Their clinical examination, patient's records, and radiographic images of nasal bone fractures were evaluated. RESULTS: Patients ranged from children to elderly. There were 156 (87.2%) males and 23 (12.8%) females. Traffic accident (36.9%) was the most common cause of nasal fracture. Orbit fracture (44 patients, 24.6%) was the most common fracture associated with a nasal bone fracture.Complications after surgery included postoperative deformity in 20 (11.2%) patients, nasal obstruction in 11 (6.1%) patients, and olfactory disturbances in 2 (1.1%) patients and patients with more severe nasal bone fractures had higher rates of these complications. CONCLUSION: Closed reduction could be performed successfully within 2 weeks after injury.

Prenatal 3D sonography of an isolated lateral facial cleft.

Lateral facial cleft is a rare congenital anomaly, but all affected infants require surgery under general anesthesia. Conventional 2-dimensional coronal view of the face, which is typically used for identification of facial clefts, has limitations with regard to detection of this anomaly. We describe a case of prenatal diagnosis of isolated lateral facial cleft made with 3D sonography and highlight the importance of this tool in the diagnosis of this rare facial deformity.

Safety of umbilical cord milking in very preterm neonates: a randomized controlled study.

OBJECTIVE: To investigate the safety of umbilical cord milking on both the mother and neonate among very preterm deliveries of less than 33 weeks of gestation. METHODS: Pregnant women who were expected to deliver at between 24 0/7 and 32 6/7 weeks of gestation were randomized to either the umbilical cord milking or immediate cord clamping group. Maternal and neonatal data associated with delivery, in addition to neonatal morbidity and mortality data, were collected and analyzed. RESULTS: Of the 66 preterm deliveries included in the study, 34 were randomized into the milking and 32 into the clamping group. Differences between maternal pre- and post-partum hemoglobin levels were 1.35 g/dL in the milking and 1.58 g/dL in the clamping group (P=0.451). Neonatal Apgar scores at both 1 and 5 minutes, initial blood gas analysis results, body temperature at admission, need for early intubation, and maximum bilirubin levels were all similar between the 2 groups. However, neonatal hemoglobin levels at birth (15.79 vs. 14.69 g/dL; P<0.05) and at 24 hours of age (14.83 vs. 13.29 g/dL; P<0.05) were significantly higher in the milking group. Neonates in the clamping group required more blood transfusion (1.78 vs. 0.93; P=0.049), and a higher percentage of neonates in the clamping group required inotropic drugs (63% vs. 29%; P=0.007). The mortality rate was significantly lower in the milking group (6% vs. 28%; P=0.015). CONCLUSION: Umbilical cord milking can be a safe and beneficial procedure for both the mother and the neonate in deliveries of less than 33 weeks of gestation.

Lower limb compartment syndrome by reperfusion injury after treatment of arterial thrombosis post-laparoscopic radical hysterectomy and pelvic lymph node dissection for cervical cancer.

Compartment syndrome is a clinical condition associated with decreased blood circulation that can lead to swelling of tissue in limited space. Several factors including lithotomy position, prolonged surgery, intermittent pneumatic compressor, and reperfusion after treatment of arterial thrombosis may contribute to compartment syndrome. However, compartment syndrome rarely occurs after gynecologic surgery. In this case, the patient was diagnosed as compartment syndrome due to reperfusion injury after treatment of arterial thrombosis, which occurred after laparoscopic radical hysterectomy and pelvic lymph node dissection for cervical cancer. Despite its rarity, prevention and identifying the risk factors of complication should be performed perioperatively; furthermore, gynecologist should be aware of the possibility of complications.

IL-12 and IL-23 Production in Toxoplasma gondii- or LPS-Treated Jurkat T Cells via PI3K and MAPK Signaling Pathways.

IL-12 and IL-23 are closely related in structure, and have been shown to play crucial roles in regulation of immune responses. However, little is known about the regulation of these cytokines in T cells. Here, we investigated the roles of PI3K and MAPK pathways in IL-12 and IL-23 production in human Jurkat T cells in response to Toxoplasma gondii and LPS. IL-12 and IL-23 production was significantly increased in T cells after stimulation with T. gondii or LPS. T. gondii and LPS increased the phosphorylation of AKT, ERK1/2, p38 MAPK, and JNK1/2 in T cells from 10 min post-stimulation, and peaked at 30-60 min. Inhibition of the PI3K pathway reduced IL-12 and IL-23 production in T. gondii-infected cells, but increased in LPS-stimulated cells. IL-12 and IL-23 production was significantly reduced by ERK1/2 and p38 MAPK inhibitors in T. gondii- and LPS-stimulated cells, but not in cells treated with a JNK1/2 inhibitor. Collectively, IL-12 and IL-23 production was positively regulated by PI3K and JNK1/2 in T. gondii-infected Jurkat cells, but negatively regulated in LPS-stimulated cells. And ERK1/2 and p38 MAPK positively regulated IL-12 and IL-23 production in Jurkat T cells. These data indicate that T. gondii and LPS induced IL-12 and IL-23 production in Jurkat T cells through the regulation of the PI3K and MAPK pathways; however, the mechanism underlying the stimulation of IL-12 and IL-23 production by T. gondii in Jurkat T cells is different from that of LPS.

Trichomonas vaginalis Induces SiHa Cell Apoptosis by NF-κB Inactivation via Reactive Oxygen Species.

Trichomonas vaginalis induces apoptosis in host cells through various mechanisms; however, little is known about the relationship between apoptosis, reactive oxygen species (ROS), and NF-κB signaling pathways in the cervical mucosal epithelium. Here, we evaluated apoptotic events, ROS production, and NF-κB activity in T. vaginalis-treated cervical mucosal epithelial SiHa cells, with or without specific inhibitors, using fluorescence microscopy, DNA fragmentation assays, subcellular fractionation, western blotting, and luciferase reporter assay. SiHa cells treated with live T. vaginalis at a multiplicity of infection of 5 (MOI 5) for 4 h produced intracellular and mitochondrial ROS in a parasite-load-dependent manner. Incubation with T. vaginalis caused DNA fragmentation, cleavage of caspase 3 and PARP, and release of cytochrome c into the cytoplasm. T. vaginalis-treated SiHa cells showed transient early NF-κB p65 nuclear translocation, which dramatically dropped at 4 h after treatment. Suppression of NF-κB activity was dependent on parasite burden. However, treatment with the ROS scavenger, N-acetyl-C-cysteine (NAC), reversed the effect of T. vaginalis on apoptosis and NF-κB inactivation in SiHa cells. Taken together, T. vaginalis induces apoptosis in human cervical mucosal epithelial cells by parasite-dose-dependent ROS production through an NF-κB-regulated, mitochondria-mediated pathway.

Relationship between uterine volume and discontinuation of treatment with levonorgestrel-releasing intrauterine devices in patients with adenomyosis.

OBJECTIVE: This study is to evaluate the relationship between the uterine volume and the failure of levonorgestrel-releasing intrauterine device (LNG-IUD) in patients with adenomyosis. METHODS: A total of 171 women with adenomysis were treated with LNG-IUD from November 2009 to December 2011. The amount of menorrhagia, degree of dysmenorrhea, and the uterine volume were compared before and after insertion of LNG-IUD, and the treatment failure of LNG-IUD was observed. RESULTS: The mean age of the participants was 42.5 years (range 29-53 years). The mean uterine volume was 158 mL (range 46-769 mL). Among the total participants, 37 (21.6 %) discontinued the treatment prematurely. There were no different characteristics between the ongoing treatment group and treatment failure group with LNG-IUD. However, there was significant difference of uterine volume between two groups (178 ± 14 and 141 ± 7 mL, P = 0.010). Based on the receiver operator characteristic analysis, the optimum cutoff value of uterine volume more than 150 mL was significantly associated with failure of LNG-IUD (area under curve: 0.763, 95 % CI 0.669-0.856). In univariate analysis, the uterine volume more than 150 mL was the only independent factor for the failure of LNG-IUD (odds ratio 6.76, 95 % CI 1.20-38.02, P = 0.030). CONCLUSION: The rate of treatment failure after LNG-IUD insertion for the patients with adenomyosis was related to the uterine volume. Specifically, the treatment failure rate of large volume uterus (>150 mL) with LNG-IUD was significantly higher than that of small volume uterus.

Two pregnancy cases of uterine scar dehiscence after laparoscopic myomectomy.

Uterine scar dehiscence following laparoscopic myomectomy rarely occurs but can compromise both maternal and fetal well-being in subsequent pregnancy. We here present two cases of pregnancy complicated by preterm birth that resulted from uterine scar dehiscence following laparoscopic myomectomy. First case was a nulligravida who had scar dehiscence at 26 weeks of gestation after having a laparoscopic myomectomy 3 months prior to conception. Two weeks later, we observed her fetal leg protruding through the defect. The other case was a primigravida with a history of prior cesarean delivery, whose sonography revealed myomectomy scar dehiscence at 31 weeks of gestation. Within a few hours after observing, the patient complained of abdominal pain that was aggravating as fetal leg protruded through the defect. In both cases, babies were born by emergency cesarean section. Conservative management can be one of treatment options for myomectomy scar dehiscence in preterm pregnancy. However, clinicians should always be aware of the possibility of obstetric emergencies.

Differential microscopic finding and glucose transporter 3 expression in terminal chorionic villi among birth weight-discordant twin placentas.

OBJECTIVE: To evaluate differences in microscopic findings and glucose transporter 3 (GLUT3) expression in terminal chorionic villi (TV) among birth weight-discordant twin (BWDT) placentas compared with the birth weight-concordant twin (BWCT) placentas. METHODS: We retrospectively studied a cohort of 26 BWDT, 10 BWCT, 10 pre-eclampsia singleton and 10 normal singleton pregnancies. Placentas were scored for the percentage of TV, the percentage of TV with syncytial knots, the presence of capillary branching patterns of TV, the capillary to terminal villous ratios, the membranous expression of GLUT3 and the nuclear expression of HIF-1α in trophoblasts and capillary endothelial cells of TV using immunohistochemistry. The clinical characteristics and microscopic findings were analyzed and compared. RESULTS: BWDT placentas exhibited differential percentages of TV, percentages of TV with syncytial knots, capillary to terminal villous ratios, expression of HIF-1α in capillary endothelial cells and expression of GLUT3 in trophoblasts and capillary endothelial cells of TV among each twin pair compared with BWCT placentas (P=0.003, P=0.022, P=0.037, P=0.007, P=0.046 and P=0.002, respectively). Pre-eclampsia singleton placentas exhibited higher GLUT3 expression in trophoblasts, higher HIF-1α expression in capillary endothelial cells of TV and high capillary to terminal villous ratios compared with normal singleton placentas (P=0.001, P<0.001 and P=0.001, respectively). CONCLUSIONS: We observed a strong relationship between characteristics of adaptive change to hypoxia (GLUT3 expression, TV and syncytial knotting and higher capillary to terminal villous ratios) and BWDT pregnancy but not BWCT pregnancy.

Trichonomas vaginalis metalloproteinase induces apoptosis of SiHa cells through disrupting the Mcl-1/Bim and Bcl-xL/Bim complexes.

To elucidate the roles of metalloproteinases and the Bcl-2 family of proteins in Trichovaginalis. vaginalis-induced apoptosis in human cervical cancer cells (SiHa cells) and vaginal epithelial cells (MS74 cells), SiHa cells and MS74 cells were incubated with live T. vaginalis, T. vaginalis excretory and secretory products (ESP), and T. vaginalis lysates, either with or without the specific metalloproteinase inhibitor 1,10-phenanthroline (1,10-PT), and examined apoptotic events and Bcl-2 signaling. The live T. vaginalis and the T. vaginalis ESP induced the release of cytochrome c into the cytosol, the activation of caspase-3 and caspase-9, and the cleavage of PARP. Additionally, the live T. vaginalis, but not the T. vaginalis lysate, induced the cleavage of the proapoptotic Bim protein. The live T. vaginalis and the T. vaginalis ESP, but not the T. vaginalis lysate, induced the dose-dependent cleavage of the antiapoptotic Bcl-xL and Mcl-1 proteins and decreased the association levels of Bcl-xL/Bim and Mcl-1/Bim complexes. We performed gelatin zymography and casein-hydrolysis assays on the live T. vaginalis and the T. vaginalis ESP to identify the apoptosis-inducing factor. Both the live T. vaginalis and the ESP contained high levels of metalloproteinases, of which activities were significantly inhibited by 1,10-PT treatment. Furthermore, the 1,10-PT blocked the cleavage of Bcl-xL, Mcl-1, PARP, caspase-3, and caspase-9, as well as the release of cytochrome c into the cytosol, and it significantly increased the association levels of the Bcl-xL/Bim and Mcl-1/Bim protein complexes, returning them to normal levels. Our results demonstrate that T. vaginalis induces mitochondria-dependent apoptosis in SiHa cells through the dissociation of Bcl-xL/Bim and Mcl-1/Bim complexes and that the apoptosis is blocked by the metalloproteinase inhibitor 1,10-PT. These results expand our understanding of the role of metalloproteinases in T. vaginalis-induced apoptosis and the signaling pathway in trichomoniasis of the cervicovaginal epithelial cells.

The efficacy of the levonorgestrel-releasing intrauterine system in perimenopausal women with menorrhagia or dysmenorrhea.

OBJECTIVE: To evaluate the hysterectomy rates and the risk factors for hysterectomy during the first 2 years of use of a levonorgestrel-releasing intrauterine system (LNG-IUS) in perimenopausal women who had complaints of either menorrhagia or dysmenorrhea. METHODS: One hundred ninety-two women over 40 years old were retrospectively analyzed for a 2-year follow-up period. The changes in the amount and duration of bleeding and the pain scores were checked at 3, 6, 12 and 24 months. RESULTS: Twenty-six (13.5%) women failed with LNG-IUS treatment and they received hysterectomy. Age, parity, the type of diseases, the amount of menstrual bleeding, the mean duration of persisted menorrhagia and the severity of pain before treatment were not the factors affecting removal of the LNG-IUS and undergoing hysterectomy. However, the pain score of the third month and the amount of bleeding on the sixth month were the factors affecting undergoing hysterectomy (P < 0.05). When hysterectomy was performed, the average duration from LNG-IUS insertion to hysterectomy was 8.9 months. The participants who persisted with the LNG-IUS treatment for 24 months showed a success rate of 80.7%. CONCLUSION: LNG-IUS is an effective device for the treatment of perimenopausal women who have complaints of either menorrhagia or dysmenorrhea. Insufficient reduction of pain score during the first 3 months and menstrual blood loss during the first 6 months after insertion of the LNG-IUS were important factors that affected undergoing hysterectomy.