Bliss procedure for undescended ovaries.

OBJECTIVE: To highlight a novel surgical approach for the management of undescended ovaries in those presenting with infertility, to allow for potential transvaginal egg retrieval. The video demonstrates a novel surgical approach for mobilization and oophoropexy of undescended ovaries to allow for future transvaginal egg retrieval in the context of artificial reproductive technology (ART). DESIGN: Case report. Institutional Review Board approval is not required because this was not a human study. Patient consent was obtained for video footage. SETTING: Hospital. PATIENTS: We present a 26-year-old nulligravid woman with a unicornuate uterus, a high riding-right ovary, and an undescended left ovary with prior laparoscopic remnant uterine horn resection. Because of her 9 years of infertility and a prior unsuccessful ovarian mobilization and oophoropexy, she was referred for consideration of a repeat laparoscopic bilateral ovarian mobilization and oophoropexy. INTERVENTION: Surgical intervention for undescended ovaries. MAIN OUTCOME MEASURES: Postoperative ovarian location and postoperative pain. RESULTS: The patient reported minimal pain postoperatively at 6 weeks. Multiple follow-up imaging revealed both ovaries behind the uterus (antral follicle counts 15), with easy transvaginal access for future ART. CONCLUSION: Undescended ovary is uncommon and usually requires no treatment. However, intervention may be required in the context of infertility and ART, where transvaginal egg retrieval is impossible because of the location of the ovaries. This is the first educational video to our knowledge highlighting a novel surgical approach for the management of undescended ovaries.

Evaluation of Radiofrequency Endometrial Ablation: A 17-year Canadian Experience.

STUDY OBJECTIVE: The purpose of this study was to better elucidate radiofrequency endometrial ablation (REA) durability by assessing the probability of failure as defined by need for postablation hysterectomy. Age at index REA, duration from REA until hysterectomy, and REA failure (REAF) risk factors were analyzed. DESIGN: A retrospective cohort study was conducted using patient data between April 1, 2002, and March 31, 2019. REAF cases were identified using operative procedure codes. Cox proportional hazard regression assessed the effect of age at index REA on time to postablation hysterectomy. Kaplan-Meier survival curve evaluated timing of postablation hysterectomy, stratified by age at index REA. SETTING: This study was conducted at Regina General Hospital in Regina, Saskatchewan, Canada. PATIENTS: Patient population included those who were 21 years of age or older, were premenopausal, and had a history of heavy menstrual bleeding at the time of REA. INTERVENTIONS: The intervention under investigation was REA. MEASUREMENTS AND MAIN RESULTS: The overall probability of postablation hysterectomy was 22.6%. The probabilities of postablation hysterectomy were 36.1% for women younger than 30 years (n = 128), 28% for women 30 to 34.9 years old (n = 528), 29.6% for women 35 to 39.9 years old (n = 1152), and 17.6% for women 40 years and older (n = 2221). Characteristics associated with REAF included tubal occlusion, cesarean section, dysmenorrhea, and chronic pelvic pain (p <.01) among women younger than 40 years. Leiomyomas accounted for higher failure rates in women 40 years and older (p <.01). CONCLUSION: Postablation hysterectomy is more likely to occur in women younger than 40 years. REA can be considered in women aged 30 to 39.9 years old, who have no known REAF risk factors. Women younger than 40 years with REAF risk factors will experience higher rates of hysterectomy. Thus, the decision to proceed with REA should be individualized with careful consideration for the underlying causes of abnormal uterine bleeding, while respecting patient autonomy.

More Than a Myoma: A Review of Myomatous Erythrocytosis Syndrome.

Myomatous erythrocytosis syndrome (MES) is gynaecological condition marked by isolated erythrocytosis and a fibroid uterus. This report presents a case of MES and reviews common clinical presentations, hematological trends, and patient outcomes. This study was a combined case report and review of published cases of MES. Cases were identified using Medline and EMBASE databases. Binomial statistics were used to compare clinical characteristics among patients with MES. Kruskal-Wallis one-way analysis of variance was used to compare hematological values across time points (Canadian Task Force Classification III). A total of 57 cases of MES were reviewed. The mean age at presentation was 48.7 years. Commonly reported signs or symptoms at presentation include abdominopelvic distension or mass (93%), skin discolouration (33%), and menstrual irregularities (25%). There was no difference in parity (P = 0.42), menopausal status (P = 0.87), or hydronephrosis on imaging (P = 0.48) among patients. Preoperative phlebotomy to reduce the risk of thromboembolic complications was performed in half of all cases. On average, a 51% reduction in serum erythropoietin levels was observed following surgical resection (P = 0.004). In conclusion, patients with MES present with signs and symptoms attributed to either an abdominopelvic mass or erythrocytosis. Preoperative phlebotomy to decrease the severity of erythrocytosis has been used to mitigate the risk of thrombotic complications. Surgical resection of the offending leiomyoma is a valid approach for the treatment of MES.

Increasing the Technicity Index to 92% in a Community Hospital: A 5-Year Retrospective Review.

OBJECTIVE: This study describes the observed trends in hysterectomy routes at Langley Memorial Hospital (LMH) in Langley, British Columbia, over 5 consecutive years. Associations between patient characteristics and surgical approach were explored, and approach-based surgical outcomes were evaluated using the institutional technicity index (TI), defined as the ratio of hysterectomies performed by minimally invasive surgery to all hysterectomies. METHODS: A retrospective descriptive study involving 706 women who underwent hysterectomy at LMH between January 1, 2012 and December 31, 2016 by six full-time surgeons was performed. From the patient characteristics and surgical outcomes associated with the route of hysterectomy, the annual institutional and overall rates of hysterectomy by type were calculated according to the Canadian Task Force Classification II-2. RESULTS: The TI increased from 67% to 92% from 2012 to 2016. Specifically, the proportion of hysterectomies completed by a total laparoscopic approach increased from 37% to 78%, whereas hysterectomies performed by the abdominal or laparoscopic-assisted vaginal approach decreased from 32% to 8% and from 17% to 1%, respectively. Vaginal hysterectomy rates remained constant across the study period. Minimally invasive surgery was associated with significantly reduced surgical blood loss and decreased length of hospital stay, with no difference in surgical time compared with an open approach. CONCLUSIONS: As far as the study investigators are aware, the TI at LMH is among the highest reported to date in Canada. Potential contributing factors include well-trained and experienced gynaecologic surgeons, readily available peer-to-peer mentorship, certified gynaecologic assistance, dedicated surgical staff, and consistency in the operating room set-up. Hence, achieving a high TI in a community setting is feasible without increasing the risk of surgical complications or length of surgery.

Abdominal Wall Pain in Women With Chronic Pelvic Pain.

OBJECTIVE: To investigate the role of abdominal wall pain (AWP) in women with pelvic pain. METHODS: We conducted a retrospective review of consecutive patients with pelvic pain seen in a tertiary referral centre between January and December 2012. AWP was defined as abdominal wall tenderness with a positive Carnett test (i.e., tenderness that worsened or remained the same with abdominal wall contraction). Pairwise comparisons were carried out between clinical variables (e.g., chronic pelvic pain) and AWP. This was followed by multiple logistic regression to identify the clinical variables with an independent association with AWP. RESULTS: The prevalence of AWP in women with pelvic pain was 67% (127/190). On multiple logistic regression, AWP was independently associated with chronic pelvic pain (OR 13.8; 95% CI 3.71 to 51.2, P < 0.001), but not with other symptoms including dysmenorrhea, deep and superficial dyspareunia, or bowel and bladder symptomology. In a corollary analysis, women with AWP were more likely to require opioids or pain adjuvants than women without AWP (P = 0.015 and P < 0.001). CONCLUSION: AWP is common in women with pelvic pain and may contribute specifically to the symptom of chronic pelvic pain.

Bladder base tenderness in the etiology of deep dyspareunia.

INTRODUCTION: Bladder base tenderness can be present on pelvic exam in women with pelvic pain. However, its exact prevalence and clinical implications are not well understood. AIM: The aim of this study was to determine whether bladder base tenderness is associated with specific symptoms or signs in women, particularly dyspareunia. METHODS: Retrospective review of 189 consecutive women seen by a gynecologist in 2012 at a tertiary referral center for pelvic pain was conducted. Associations were tested between bladder base tenderness and variables on history/examination using bivariate analyses and multiple logistic regression. MAIN OUTCOME MEASURE: Deep dyspareunia and superficial dyspareunia (present/absent) were the main outcome measures. RESULTS: Bladder base tenderness was present in 34% of pelvic pain patients (65/189), which was significantly greater than the prevalence of bladder base tenderness of 3% (1/32) in a control sample of women without pelvic pain (odds ratio [OR] = 16.3, 95% confidence interval [CI] 2.17-121.7, Fisher exact test, P < 0.001). For the pelvic pain patients, on bivariate analyses, bladder base tenderness was significantly associated with deep dyspareunia (P < 0.001), superficial dyspareunia (P < 0.001), bladder symptoms (P = 0.026), abdominal wall trigger point (P < 0.001), and pelvic floor tenderness (P < 0.001). In contrast, bladder base tenderness was similarly present in women with or without endometriosis. On logistic regression, bladder base tenderness was independently associated with only deep dyspareunia (OR = 6.40, 95% CI: 1.25-32.7, P = 0.011), abdominal wall trigger point (OR = 3.44, 95% CI: 1.01-11.7, P = 0.037), and pelvic floor tenderness (OR = 8.22, 95% CI: 3.27-20.7, P < 0.001). CONCLUSIONS: Bladder base tenderness is present in one-third of women with pelvic pain, and contributes specifically to the symptom of deep dyspareunia. Bladder base tenderness was also associated with the presence of an abdominal wall trigger point and with pelvic floor tenderness, suggesting a myofascial etiology and/or nervous system sensitization.

An analysis of patient presentations at a 2-day mass-participation cycling event: the Ride to Conquer Cancer Case Series, 2010-2012.

OBJECTIVE: To analyze the unique factors involved in providing medical support for a long-distance, cross-border, cycling event, and to describe patient presentations and event characteristics for the British Columbia (BC) Ride to Conquer Cancer from 2010 through 2012. METHODS: This study was a 3-year, descriptive case series report. Medical encounters were documented, prospectively, from 2010-2012 using an online registry. Data for event-related variables also were reported. RESULTS: Providing medical support for participants during the 2-day ride was complicated by communication challenges, weather conditions, and cross-border issues. The total number of participants for the ride increased from 2,252 in 2010 to 2,879 in 2011, and 3,011 in 2012. Patient presentation rates (PPRs) of 125.66, 155.26, and 198.93 (per 1,000 participants) were documented from 2010 through 2012. Over the course of three years, and not included in the PPR, an additional 3,840 encounters for "self-treatment" were documented. CONCLUSIONS: The Ride to Conquer Cancer Series has shown that medical coverage at multi-day, cross-national cycling events must be planned carefully to face a unique set of circumstances, including legislative issues, long-distance communication capabilities, and highly mobile participants. This combination of factors leads to potentially higher PPRs than have been reported for noncycling events. This study also illuminates the additional workload "self-treatment" visits place on the medical team.

An organized medical response for the Vancouver International Marathon (2006-2011): when the rubber hits the road.

OBJECTIVE: We described an organized, on-site medical response for a large-scale urban marathon event and documented illness/injury rates as well as ambulance transfer rates at the Vancouver International Marathon (VIM). METHODS: Case-series report of medical encounters was documented prospectively over a 6-yr period at the VIM. The planning and organization of the on-site medical response is the main focus of this report. RESULTS: A total of 67,402 runners participated in the VIM from 2006 to 2011. Over the 6-yr period, 2,986 patient encounters were documented. The patient presentation rate for the series was 45/1,000, the ambulance transfer rate was 0.09-0.58/1,000, and the medical transfer rate was 0.37-1.09/1,000. CONCLUSION: A coordinated on-site medical team covering the entire event site and race route was deployed to reduce the severity of illness and injury at a long-distance running event.

Pelvic floor tenderness in the etiology of superficial dyspareunia.

OBJECTIVE: To calculate the prevalence of pelvic floor tenderness in the population of women with pelvic pain and to determine its implications for symptoms of pelvic pain. METHODS: We conducted a retrospective review of patients with pelvic pain at a tertiary referral centre. Pelvic floor tenderness was defined as levator ani tenderness on at least one side during single digit pelvic examination. The prevalence of pelvic floor tenderness in this cohort of women with pelvic pain was compared with the prevalence in a cohort of women without pain attending a gynaecology clinic. In the women with pelvic pain, multiple regression was performed to determine which variables were independently associated with pelvic floor tenderness. RESULTS: The prevalence of pelvic floor tenderness was 40% (75/189) in the cohort with pelvic pain, significantly greater than the prevalence of 13% (4/32) in the cohort without pain (OR 4.61; 95% CI 1.55 to 13.7, P = 0.005). On multiple logistic regression, superficial dyspareunia (OR 4.45; 95% CI 1.86 to 10.7, P = 0.001), abdominal wall pain (OR 4.04; 95% CI 1.44 to 11.3, P = 0.005), and bladder base tenderness (OR 4.65; 95% CI 1.87 to 11.6, P = 0.001) were independently associated with pelvic floor tenderness. Pelvic floor tenderness was similarly present in women with or without underlying endometriosis. CONCLUSION: Pelvic floor tenderness is common in women with pelvic pain, with or without endometriosis, and is a contributor to superficial dyspareunia. Pelvic floor tenderness was also associated with abdominal wall pain and bladder base tenderness, suggesting that nervous system sensitization is involved in the etiology of pelvic floor tenderness.

Objectif : Calculer la prévalence de la sensibilité du plancher pelvien au sein de la population des femmes qui connaissent des douleurs pelviennes et déterminer ses implications pour ce qui est des symptômes de la douleur pelvienne. Méthodes : Nous avons mené une analyse rétrospective auprès de patientes connaissant des douleurs pelviennes au sein d'un centre spécialisé tertiaire. La sensibilité du plancher pelvien a été définie comme étant une sensibilité du muscle releveur de l'anus ressentie au moins d'un côté au cours d'un examen pelvien mené au moyen d'un seul doigt. La prévalence de la sensibilité du plancher pelvien au sein de cette cohorte de femmes connaissant des douleurs pelviennes a été comparée à la même prévalence au sein d'une cohorte de femmes exemptes de douleurs fréquentant une clinique de gynécologie. Chez les femmes connaissant des douleurs pelviennes, une régression multiple a été menée en vue d'identifier les variables qui étaient associées de façon indépendante à la sensibilité du plancher pelvien. Résultats : La prévalence de la sensibilité du plancher pelvien était de 40 % (75/189) au sein de la cohorte « douleurs pelviennes ¼; elle était donc considérablement supérieure à la prévalence de 13 % (4/32) qui a été constatée au sein de la cohorte « absence de douleur ¼ (RC, 4,61; IC à 95 %, 1,55 - 13,7, P = 0,005). Dans le cadre de la régression logistique multiple, la dyspareunie superficielle (RC, 4,45; IC à 95 %, 1,86 - 10,7, P = 0,001), la douleur ressentie au niveau de la paroi abdominale (RC, 4,04; IC à 95 %, 1,44 - 11,3, P = 0,005) et la sensibilité de la base de la vessie (RC, 4,65; IC à 95 %, 1,87 - 11,6, P = 0,001) étaient associées de façon indépendante à la sensibilité du plancher pelvien. Cette dernière était tout aussi présente chez les femmes qui connaissaient une endométriose sous-jacente que chez les femmes qui ne connaissaient pas une telle pathologie. Conclusion : La sensibilité du plancher pelvien est courante chez les femmes qui connaissent des douleurs pelviennes, en présence ou non d'une endométriose, et contribue à la dyspareunie superficielle. Elle a également été associée à la douleur ressentie au niveau de la paroi abdominale et à la sensibilité de la base de la vessie, ce qui semble indiquer que la sensibilisation du système nerveux est impliquée dans son étiologie.

A fish eye out of water: ten visual opsins in the four-eyed fish, Anableps anableps.

The "four-eyed" fish Anableps anableps has numerous morphological adaptations that enable above and below-water vision. Here, as the first step in our efforts to identify molecular adaptations for aerial and aquatic vision in this species, we describe the A. anableps visual opsin repertoire. We used PCR, cloning, and sequencing to survey cDNA using unique primers designed to amplify eight sequences from five visual opsin gene subfamilies, SWS1, SWS2, RH1, RH2, and LWS. We also used Southern blotting to count opsin loci in genomic DNA digested with EcoR1 and BamH1. Phylogenetic analyses confirmed the identity of all opsin sequences and allowed us to map gene duplication and divergence events onto a tree of teleost fish. Each of the gene-specific primer sets produced an amplicon from cDNA, indicating that A. anableps possessed and expressed at least eight opsin genes. A second PCR-based survey of genomic and cDNA uncovered two additional LWS genes. Thus, A. anableps has at least ten visual opsins and all but one were expressed in the eyes of the single adult surveyed. Among these ten visual opsins, two have key site haplotypes not found in other fish. Of particular interest is the A. anableps-specific opsin in the LWS subfamily, S180gamma, with a SHYAA five key site haplotype. Although A. anableps has a visual opsin gene repertoire similar to that found in other fishes in the suborder Cyprinodontoidei, the LWS opsin subfamily has two loci not found in close relatives, including one with a key site haplotype not found in any other fish species. A. anableps opsin sequence data will be used to design in situ probes allowing us to test the hypothesis that opsin gene expression differs in the distinct ventral and dorsal retinas found in this species.

The Escherichia coli mismatch repair protein MutL recruits the Vsr and MutH endonucleases in response to DNA damage.

The activities of the Vsr and MutH endonucleases of Escherichia coli are stimulated by MutL. The interaction of MutL with each enzyme is enhanced in vivo by 2-aminopurine treatment and by inactivation of the mutY gene. We hypothesize that MutL recruits the endonucleases to sites of DNA damage.