Feasibility of Predicting Surgical Duration in Endometriosis Using Numerical Multi-Scoring System of Endometriosis (NMS-E).

BACKGROUND: Endometriosis is a multifaceted gynecological condition that poses diagnostic challenges and affects a significant number of women worldwide, leading to pain, infertility, and a reduction in patient quality of life (QoL). Traditional diagnostic methods, such as the revised American Society for Reproductive Medicine (r-ASRM) classification, have limitations, particularly in preoperative settings. The Numerical Multi-Scoring System of Endometriosis (NMS-E) has been proposed to address these shortcomings by providing a comprehensive preoperative diagnostic tool that integrates findings from pelvic examinations and transvaginal ultrasonography. METHODS: This retrospective study aims to validate the effectiveness of the NMS-E in predicting surgical outcomes and correlating with the severity of endometriosis. Data from 111 patients at Nippon Medical School Hospital were analyzed to determine the correlation between NMS-E scores, including E-score-a severity indicator-traditional scoring systems, surgical duration, blood loss, and clinical symptoms. This study also examined the need to refine parameters for deep endometriosis within the NMS-E to enhance its predictive accuracy for disease severity. RESULTS: The mean age of the patient cohort was 35.1 years, with the majority experiencing symptoms such as dysmenorrhea, dyspareunia, and chronic pelvic pain. A statistically significant positive correlation was observed between the NMS-E's E-score and the severity of endometriosis, particularly in predicting surgical duration (Spearman correlation coefficient: 0.724, p < 0.01) and blood loss (coefficient: 0.400, p < 0.01). The NMS-E E-score also correlated strongly with the r-ASRM scores (coefficient: 0.758, p < 0.01), exhibiting a slightly more excellent predictive value for surgical duration than the r-ASRM scores alone. Refinements in the methodology for scoring endometriotic nodules in uterine conditions improved the predictive accuracy for surgical duration (coefficient: 0.752, p < 0.01). CONCLUSIONS: Our findings suggest that the NMS-E represents a valuable preoperative diagnostic tool for endometriosis, effectively correlating with the disease's severity and surgical outcomes. Incorporating the NMS-E into clinical practice could significantly enhance the management of endometriosis by addressing current diagnostic limitations and guiding surgical planning.

Clinical Significance of a Pain Scoring System for Deep Endometriosis by Pelvic Examination: Pain Score.

Endometriosis-associated pain is an essential factor in deciding surgical indications of endometriosis. However, there is no quantitative method to diagnose the intensity of local pain in endometriosis (especially deep endometriosis). This study aims to examine the clinical significance of the pain score, a preoperative diagnostic scoring system for endometriotic pain that can be performed only with pelvic examination, devised for the above purpose. The data from 131 patients from a previous study were included and evaluated using the pain score. This score measures the pain intensity in each of the seven areas of the uterus and its surroundings via a pelvic examination using a numeric rating scale (NRS) which contains 10 points. The maximum value was then defined as the max pain score. This study investigated the relationship between the pain score and clinical symptoms of endometriosis or endometriotic lesions related to deep endometriosis. The preoperative max pain score was 5.93 ± 2.6, which significantly decreased to 3.08 ± 2.0 postoperatively (p = 7.70 × 10-20). Regarding preoperative pain scores for each area, those of the uterine cervix, pouch of Douglas, and left and right uterosacral ligament areas were high (4.52, 4.04, 3.75, and 3.63, respectively). All scores decreased significantly after surgery (2.02, 1.88, 1.75, and 1.75, respectively). The correlations between the max pain score and dysmenorrhea, dyspareunia, perimenstrual dyschezia (pain with defecation), and chronic pelvic pain were 0.329, 0.453, 0.253, and 0.239, respectively, and were strongest with dyspareunia. Regarding the pain score of each area, the combination of the pain score of the pouch of Douglas area and the VAS score of dyspareunia showed the strongest correlation (0.379). The max pain score in the group with deep endometriosis (endometrial nodules) was 7.07 ± 2.4, which was significantly higher than the 4.97 ± 2.3 score obtained in the group without (p = 1.71 × 10-6). The pain score can indicate the intensity of endometriotic pain, especially dyspareunia. A local high value of this score could suggest the presence of deep endometriosis, depicted as endometriotic nodules at that site. Therefore, this method could help develop surgical strategies for deep endometriosis.

Risk Factors for Abscess Development in Patients with Endometrioma Who Present with an Acute Abdomen.

Objectives: The objective of this study was to assess the potential risk factors for abscess development in patients with endometrioma who present with an acute abdomen. Materials and Methods: We retrospectively reviewed the records of 51 patients who underwent emergency surgery for acute abdomen involving an endometrioma at our hospital between April 2011 and August 2021. The patients were divided into an infected group (n = 22) and a control group (n = 29). We analyzed patient characteristics; imaging findings; clinical data, including bacterial cultures; and perioperative outcomes to assess for differences between groups. Results: Patients in the infected group were significantly older than those in the control group (P = 0.03). They were more likely to have a history of endometriosis surgery (P = 0.04) and more likely to have undergone transvaginal manipulation within 3 months of presentation (P = 0.01). Body temperature on the day of admission was significantly higher in the infected group (P = 0.007), as were C-reactive protein levels on the day of admission and before surgery (P < 0.001; P = 0.018) and the white blood cell count on the day of admission (P = 0.016). Preoperative imaging showed significant thickening of the tumor wall (P < 0.001) and an enhanced contrast effect (P < 0.001) in the infected group. Conclusion: We identified several factors that suggest abscess in patients with an acute abdomen who have a complication of pathologically confirmed endometriosis. A recent vaginal procedure is a particular risk factor for abscess development in patients with endometriomas.

Accuracy of Transvaginal Ultrasonographic Diagnosis of Retroflexed Uterus in Endometriosis, with Magnetic Resonance Imaging as Reference.

BACKGROUND: Accurate diagnosis of retroflexed uterus in daily practice is essential because this condition is related to pelvic pain and deep endometriosis. Uterine flexion can be measured by transvaginal ultrasonography (TVUS), a cost-effective primary test, but the accuracy required for diagnosing retroflexed uterus is unclear. This study assessed the accuracy of TVUS for diagnosis of retroflexed uterus in patients with endometriosis and compared it with that of magnetic resonance imaging (MRI) -the gold standard for measuring the uterine axis. METHODS: The study included 123 patients who underwent endometriosis surgery in our department between 2012 and 2017. Uterine flexion angles were measured by retrospectively examining TVUS and MRI images, and the correlation was analyzed. Analysis of anteverted and retroverted uterine subgroups identified aspects of diagnosing uterine flexion with TVUS. RESULTS: Uterine flexion angles on TVUS were strongly positively correlated (r = 0.86) with MRI results. Additionally, TVUS yielded no false-positive diagnoses and 28 false-negative diagnoses of retroflexion. All false-negative diagnoses occurred in patients with anteverted retroflexed uteruses. CONCLUSIONS: TVUS was generally accurate for measuring uterine flexion angle, as indicated by its strong correlation with MRI. Misdiagnosis of anteverted retroflexed uterus was a limitation of using TVUS for retroflexion diagnosis.

Relationship Between Prehospital Time and 24-h Mortality in Road Traffic-Injured Patients in Laos.

BACKGROUND: Road traffic injury has long been regarded as a "time-dependent disease." However, shortening the prehospital time might not improve the outcome in developing countries given the current quality of in-hospital care. We aimed to examine the relationship between the prehospital time and 24-h mortality among road traffic victims in Laos. METHODS: A prospective observational study was conducted using the trauma registry data on traffic-injured patients who were transported by ambulance to a trauma center in the capital city of Laos from May 2018 to April 2019. The analysis focused on patients with non-mild conditions, whose outcomes could be affected by the prehospital time. To examine the relationship between a prehospital time of <60 min and 24-h mortality, a generalized estimating equation model was used incorporating the inverse probability weights utilizing the propensity score for the prehospital time. RESULTS: Of 701 patients, 73% were men, 91% were riding 2- or 3-wheel motor vehicles during the crash, and 68% had a prehospital time of <60 min. A total of 35 patients died within 24 h after the crash. Compared with those who survived, individuals who died tended to have head and torso injuries. The proportions of 24-h mortality were 4.7% and 5.4% in patients whose prehospital time was <60 min and ≥60 min, respectively. No significant relationship was found between the prehospital time and 24-h mortality. CONCLUSION: A shorter prehospital time was not associated with the 24-h survival among road traffic victims in Laos.

Outcome of Modified Laparoscopic Sacrocolpopexy and Its Effect on Voiding Dysfunction.

BACKGROUND: Because of its low recurrence rate and safety, laparoscopic sacrocolpopexy (LSC) is an increasingly popular treatment for pelvic organ prolapse (POP). Although LSC may improve voiding function, it can also lead to de novo stress urinary incontinence. The exact effects of LSC on voiding function, and the mechanisms responsible, remain unclear. Therefore, in this study we prospectively evaluated the impact of LSC on voiding function by performing a pre- and postoperative urodynamic study of patients with stage 3 or worse POP. METHODS: Urinary status was evaluated before and 3 months after LSC. Pre- and postoperative evaluations included medical history, clinical examination, urodynamic studies, chain cystography, and residual urine volume measurement. Urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) and the Overactive Bladder Symptom Score (OABSS). RESULTS: The nonrecurrence rate at 3 months was 82.3%. All recurrences involved bladder prolapse. In addition to the absence of a significant change in OABSS, the improvement in IPSS suggests that subjective voiding symptoms improved. Although the maximum urinary flow rate did not significantly change, bladder volume at first sensation increased, urinary storage function improved, and residual urine volume decreased. There were no perioperative complications, and no patient reported postoperative difficulty in urination or urinary retention. The retrovesical angle significantly decreased. CONCLUSIONS: The modified LSC in women with POP provides good functional outcomes in terms of IPSS, post-void residual volume (PVR), and urinary storage function.

A Case of an Abscessed Cystic Endometriotic Lesion in the Vesico-uterine Pouch after Oocyte Retrieval.

A 31-year-old nulliparous Japanese woman visited the clinic due to worsening dysmenorrhea. A cystic endometriotic lesion was found in the vesico-uterine pouch. Laparoscopic surgery was chosen due to the severe dysmenorrhea. Her first oocyte retrieval attempt was performed at in-vitro fertilization clinic before the planned surgery. However, she complained of abdominal pain on day 6 after the retrieval. We diagnosed her with peritonitis with an abscessed cystic endometriotic lesion in the vesico-uterine pouch. Conservative treatment was ineffective. Therefore, laparoscopic surgery was performed. The cysts in the vesico-uterine pouch were drained of pus. No adhesions or lesions of endometriosis in the uterus, bilateral adnexa, or pelvic peritoneum were found. Although cystic endometriotic lesions in the vesico-uterine pouch are rare, they can form abscesses after oocyte retrieval. The possibility of abscesses formation risk must be considered. Moreover, following the management of endometrioma, sufficient medication should be administered to prevent this formation.

Impact of duration of untreated psychosis on remission in first-episode schizophrenia in Thailand: a cohort study

ABSTRACT Background: To scale up the services for first-episode schizophrenia in Thailand, it is essential to understand to what extent health care-seeking is delayed, and how much the delay affects the treatment outcome. Objectives: To investigate the duration of untreated psychosis (DUP) and its impact on remission in first-episode schizophrenia across the country. Methods: 276 outpatients with a first-episode schizophrenia were followed for 6 months and assessed whether they fulfilled the criteria for remission at the follow-up. The proportion of those achieving remission was compared by the DUP. The impact of DUP on remission was estimated in multivariate analyses. Results: At the follow-up, 83% (71/86) of patients who had met the criteria for symptomatic remission at the baseline achieved enduring remission, whereas 63% (119/190) of patients who had not met the criteria for symptomatic remission at baseline met it at the follow-up. The shorter the DUP, the higher the proportion of those who achieved symptomatic or enduring remission at the follow-up. The impact of DUP on symptomatic remission appeared to be significant after controlling for other factors influencing remission. Conclusion: Since the DUP would influence remission of patients with schizophrenia, early detection and intervention services should be provided in Thailand.

Alleviating psychological distress associated with a positive cervical cancer screening result: a randomized control trial.

BACKGROUND: The method of communicating a positive cancer screening result should seek to alleviate psychological distress associated with a positive result. We evaluated whether the provision of information through a leaflet would help reduce psychological distress in a randomized controlled trial. METHODS: The participants were women aged 20-69 years who were about to undergo cervical cancer screening at health centers. Before the screening, they received hypothetical screening results, with a leaflet (intervention group, n = 493) or without it (control group, n = 479), randomly. Their psychological distress and intention to undergo further examination were then compared between the intervention and control groups. RESULTS: After the intervention (providing a leaflet with hypothetical screening results), psychological distress appeared to be higher in the control group than in the intervention group among those who received a hypothetical positive screening result (odds ratio: 2.57, 95% confidence interval: 1.87-3.54), while 95% and 97% of those in the intervention and control groups, respectively, reported that they would undergo further examination. CONCLUSIONS: Information provision might help reduce psychological distress but not hinder further examination among women who screen positive for cervical cancer. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000029894. Date of Registration: November 2017.

Case of ovarian steroid cell tumor diagnosed after presenting acute heart failure.

We report a rare case of an ovarian steroid cell tumor with a diagnosis prompted by heart failure symptoms. A 28-year-old Japanese nulligravida/nullipara with a chief complaint of respiratory discomfort during physical exertion and exhibiting heart failure symptoms was referred to our hospital. She also had signs of virilization, including secondary menorrhea since the age of 20, hirsutism and balding. Cushing's syndrome was suspected, and further examinations showed hypertestosteronemia and right ovarian tumor. Symptomatic treatment for heart failure with diuretics and antihypertensives was followed by abdominal right adnexectomy performed due to the androgen-producing ovarian tumor. The tumor was solid and larger than a fist, and confirmed as a steroid cell tumor through postoperative histopathology. Serum total testosterone levels normalized at day 3 postoperatively, and menstruation resumed 2 months later. Our case was diagnosed due to heart failure symptoms, and its treatment resulted in improvement in virilization signs.

Accuracy and clinical value of an adhesion scoring system: A preoperative diagnostic method using transvaginal ultrasonography for endometriotic adhesion.

AIM: To investigate the accuracy and clinical value of an adhesion scoring system using transvaginal ultrasonography for endometriotic adhesion. METHODS: In this prospective observational study, we included 131 patients with endometriosis who underwent surgery. Before surgery, transvaginal ultrasonography and adhesion mapping were performed to determine the presence or absence of adhesions at 10 sites of the pelvis. Mapping accuracy was determined by comparing the mapping findings with the surgical findings. To determine the severity of pelvic adhesions, we developed an adhesion score (0-10). With the adhesion score, we assessed the effect of surgical adhesiolysis and evaluated the relationship between postoperative adhesions and infertility. RESULTS: Of the 10 sites assessed for adhesions, the most frequent site of adhesions was the site between the left ovary and the uterus (70.5%). The overall sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and accuracy of adhesion mapping were 80.4%, 86.1%, 78.8%, 87.2%, 5.79, 0.23 and 83.9%, respectively. The adhesion score in this system was significantly correlated with the adhesion-related score in the revised American Society for Reproductive Medicine classification (R2 = 0.734). Surgical adhesiolysis yielded only about 30% improvement postoperatively. The adhesion score 1 month after surgery in the non-in vitro fertilization (IVF) pregnancy group was significantly lower than that in the IVF pregnancy group (3.45 vs 5.21; P = 0.02). CONCLUSION: Our adhesion scoring system allowed an accurate prediction of the pelvic adhesion status and may potentially be an indicator of postoperative adhesions and infertility.

Nutritional status and postoperative outcomes in patients with gastrointestinal cancer in Vietnam: a retrospective cohort study.

BACKGROUND: Nutritional support for surgical care is crucial because hospital malnutrition is rather common. However, low- and middle-income countries have not adequately addressed nutritional management of surgical patients. To highlight need for nutritional management in surgical patients, the present study aimed to describe preoperative nutritional status in patients who underwent gastrointestinal cancer surgery in Vietnam and to investigate the relationship between preoperative malnutrition and adverse outcomes, such as postoperative complications and prolonged length of hospital stay. METHODS: We reviewed medical records of patients who underwent a major curative surgery for gastrointestinal cancer at the national hospital in Ho Chi Minh City, Vietnam. We identified preoperative malnutrition based on body mass index and serum albumin level, and postoperative complications in the first 30 d postoperative. We estimated the relative influence of malnutrition on complications and length of hospital stay using multivariate regression models. RESULTS: Of 459 eligible patients, 63% had colorectal cancer, 33% gastric cancer, and 4% esophageal cancer. The prevalence of malnutrition was 19%. No patients died during hospitalization; however, 26% developed complications after surgery. The average length of hospital stay was 14 d. After controlling for potential confounders, preoperative malnutrition was associated with an increased risk of postoperative complications (odds ratio = 1.97) and prolonged hospital stay (2.8 d). CONCLUSIONS: Preoperative malnutrition affects surgical outcomes among patients with gastrointestinal cancer in Vietnam. We recommend implementing preoperative nutritional interventions to achieve better outcomes among surgical cancer patients.

Laparoscopic versus abdominal sacrocolpopexy for treatment of multi-compartmental pelvic organ prolapse: A systematic review.

Laparoscopic sacrocolpopexy (LSC) is attracting increasing attention as a minimally invasive surgery that provides excellent therapeutic effects on apical vaginal prolapse. However, its therapeutic effects on multi-compartmental pelvic organ prolapse (POP) remain unclear. Therefore, the aim of this review was to evaluate the efficacy of LSC on multi-compartmental POP compared with abdominal sacrocolpopexy (ASC). We extracted three articles on randomized controlled trials that compared LSC and ASC. A total of 247 patients (123 for LSC, 124 for ASC) were evaluated. There was no evidence of recurrence or reoperation in either group for the apical vaginal compartment. Regarding recurrence within the anterior vaginal compartment, there were no significant between-group differences in either of the two randomized controlled trials targeting vaginal vault prolapse. In contrast, in the randomized controlled trial targeting POP including cases with uteruses, there were more recurrent POP with grade II or more in the LSC group than in the ASC group (11/60 [18.3%] vs 1/60 [1.6%], P = 0.004). Reoperation for the posterior vaginal compartment was performed in three cases (2.5%) in the LSC group and in one case (0.8%) in the ASC group. The combined repeat surgery and mesh removal surgery rate was higher in the LSC group (8/119 [6.7%]) than in the ASC group (2/121 [1.7%], P = 0.049). LSC has an excellent therapeutic effect and is comparable to ASC for the treatment of apical prolapse. However, cystocele recurrence, repeat surgery of the posterior compartment, and mesh-related complications were more frequent in patients who had undergone LSC.

Perioperative nutrition management as an important component of surgical capacity in low- and middle-income countries.

Needs for surgical care are growing in low- and middle-income countries. Existing surgical care capacity indicators, focusing on the availability of equipment, personnel, and operation and anaesthetic skills, are not intended to evaluate perioperative nutrition management, which influences surgical outcomes. In this narrative review, we describe the prevalence of malnutrition and its clinical consequences among surgical patients in low- and middle-income countries, suggest potential measures to improve nutrition management and discuss the necessity of considering nutrition management as a component of surgical care capacity.

Psychological impact of positive cervical cancer screening results among Japanese women.

BACKGROUND: While cervical cancer screening is useful for detecting and then treating the disease at an early stage, most women with screen-positive results are free from cervical cancer but nevertheless subject to the unnecessary worry entailed in receiving such results. The purpose of this study was to examine whether receiving a screen-positive result was actually related to psychological distress among Japanese women who underwent cervical cancer screening. METHODS: We conducted a questionnaire survey at health facilities in a semiurban city of Ibaraki prefecture, involving 1744 women who underwent cervical cancer screening and 72 who received screen-positive results and then underwent further testing. We used the K6 scale to assess their psychological distress (K6 score ≥5) and performed multiple logistic regression analyses to estimate the relative effect of receiving screen-positive results on psychological distress. RESULTS: Psychological distress was more prevalent among women with screen-positive results (OR 2.22; 95 % CI 1.32-3.74), while it was also related to history of mental health consultation (OR 2.26; 95 % CI 1.69-3.01) and marital status (OR 1.32; 95 % CI 1.02-1.70). CONCLUSIONS: Receiving a positive cervical cancer screening result was associated with psychological distress. To alleviate this psychological impact, the current form of communicating the screening results should be reconsidered.

Effects of extracellular pH and hypoxia on the function and development of antigen-specific cytotoxic T lymphocytes.

The major effector cells for cellular adaptive immunity are CD8(+) cytotoxic T lymphocytes (CTLs), which can recognize and kill virus-infected cells and tumor cells. Although CTLs exhibit strong cytolytic activity against target cells in vitro, a number of studies have demonstrated that their function is often impaired within tumors. Nevertheless, CTLs can regain their cytotoxic ability after escaping from the tumor environment, suggesting that the milieu created by tumors may affect the function of CTLs. As for the tumor environment, the patho-physiological situation present in vivo has been shown to differ from in vitro experimental conditions. In particular, low pH and hypoxia are the most important microenvironmental factors within growing tumors. In the present study, to determine the effect of these factors on CTL function in vivo, we examined the cytolytic activity of CTLs against their targets using murine CTL lines and the induction of these cells from memory cells under low pH or hypoxic conditions using antigen-primed spleen cells. The results indicated that both cytotoxic activity and the induction of functional CTLs were markedly inhibited under low pH. In contrast, in hypoxic conditions, although cytotoxic activity was almost unchanged, the induction of CTLs in vitro showed a slight enhancement, which was completely abrogated in low pH conditions. Therefore, antigen-specific CTL functions may be more vulnerable to low pH than to the oxygen concentration in vivo. The findings shown here provide new therapeutic approaches for controlling tumor growth by retaining CTL cytotoxicity through the maintenance of higher pH conditions.