Videoscope-assisted transaortic myectomy in patients with hypertrophic cardiomyopathy with complex left ventricular anatomy.

BACKGROUND: The transaortic approach is the most common method of septal myectomy. However, difficulties arise due to a limited view of the surgical field. Here, we report our experience with videoscope-assisted transaortic myectomy. METHODS: We reviewed myectomy operations that were performed between July 2015 and June 2019 at Chung-Ang University Hospital, Seoul, South Korea. Patients who previously had cardiac surgery, alcohol septal ablation, or concomitant disease which required combined surgery, were excluded. Among the 21 patients included, 10 patients underwent videoscope-assisted transaortic myectomy (VA group), and 11 patients underwent myectomy in a conventional manner (CO group). The preoperative data, echocardiographic images, operative records, and postoperative outcomes of these patients were reviewed. RESULTS: There were no differences in baseline characteristics between groups VA and CO. The main indications for videoscope-assisted transaortic myectomy in group VA were midventricular septal muscle resection (70%), abnormal papillary muscle resection (40%), and abnormal chordal connection resection (30%). Eight (80%) patients had multiple indications for videoscope-assisted transaortic myectomy. There was no surgical mortality in either group. Postoperative patients showed less than moderate mitral regurgitation and a New York Heart Association class either III or IV. There were no differences in hospital days (9.5 vs. 12.0 days; p = .383), nor postoperative pressure gradient (14 vs. 15 mmHg; p > .99). CONCLUSIONS: Videoscope-assisted transaortic myectomy is an effective surgical technique in selective hypertrophic cardiomyopathy patients with complex intraventricular anatomy, diffuse hypertrophy, and midventricular obstruction.

Omega-3 Polyunsaturated Fatty Acids Prevent Toxoplasma gondii Infection by Inducing Autophagy via AMPK Activation.

Omega-3 polyunsaturated fatty acids (ω3-PUFAs) have potential protective activity in a variety of infectious diseases, but their actions and underlying mechanisms in Toxoplasma gondii infection remain poorly understood. Here, we report that docosahexaenoic acid (DHA) robustly induced autophagy in murine bone marrow-derived macrophages (BMDMs). Treatment of T. gondii-infected macrophages with DHA resulted in colocalization of Toxoplasma parasitophorous vacuoles with autophagosomes and reduced intracellular survival of T. gondii. The autophagic and anti-Toxoplasma effects induced by DHA were mediated by AMP-activated protein kinase (AMPK) signaling. Importantly, BMDMs isolated from Fat-1 transgenic mice, a well-known animal model capable of synthesizing ω3-PUFAs from ω6-PUFAs, showed increased activation of autophagy and AMPK, leading to reduced intracellular survival of T. gondii when compared with wild-type BMDMs. Moreover, Fat-1 transgenic mice exhibited lower cyst burden in the brain following infection with the avirulent strain ME49 than wild-type mice. Collectively, our results revealed mechanisms by which endogenous ω3-PUFAs and DHA control T. gondii infection and suggest that ω3-PUFAs might serve as therapeutic candidate to prevent toxoplasmosis and infection with other intracellular protozoan parasites.

Protective effects of a traditional herbal extract from Stellaria dichotoma var. lanceolata against Mycobacterium abscessus infections.

Stellaria dichotoma var. lanceolata (SdLv), a member of the Caryophyllaceae, is a traditional herbal medicine that has been used to treat fever, night sweats, and malaria in East Asia. Inflammation plays an essential role in both host defense and pathogenesis during infection by diverse intracellular pathogens. Herein, we showed that an herbal extract from SdLv effectively attenuated inflammatory responses from infection of Mycobacterium abscessus (Mab), but not Toxoplasma gondii (T. gondii). In primary murine macrophages, Mab infection resulted in the rapid activation of nuclear factor (NF)-κB and mitogen-activated protein kinase (MAPK), as well as in the generation of proinflammatory cytokines, such as tumor necrosis factor α and interleukin-6, which were all significantly inhibited by pretreatment with SdLv. However, herbal extracts from Bupleurum chinense DC. (Buch) or Bupleurum falcatum L. (Bufa) did not affect M. abs-induced activation of proinflammatory responses. Importantly, we demonstrated that generation of intracellular reactive oxygen species, which are important signaling intermediaries in the activation of NF-κB and the MAPK signaling pathway, was rapidly increased in Mab-infected macrophages, and this was effectively suppressed by pretreatment with SdLv, but not Buch and Bufa. We further found that the treatment of Buch and Bufa, but not SdLv, led to the activation of NF-κB and the MAPK signaling pathway and the generation of intracellular reactive oxygen species. Moreover, oral administration of SdLv significantly reduced lethality in Mab-infected mice. Collectively, these results suggest the possible use of SdLv as an effective treatment for Mab infection.

NADPH oxidase 4 is required for the generation of macrophage migration inhibitory factor and host defense against Toxoplasma gondii infection.

Nicotinamide adenine dinucleotide phosphate (NADPH) oxidases (Nox) are an important family of catalytic enzymes that generate reactive oxygen species (ROS), which mediate the regulation of diverse cellular functions. Although phagocyte Nox2/gp91phox is closely associated with the activation of host innate immune responses, the roles of Nox family protein during Toxoplasma gondii (T. gondii) infection have not been fully investigated. Here, we found that T. gondii-mediated ROS production was required for the upregulation of macrophage migration inhibitory factor (MIF) mRNA and protein levels via activation of mitogen-activated protein kinase and nuclear factor-κB signaling in macrophages. Interestingly, MIF knockdown led to a significant increase in the survival of intracellular T. gondii in bone marrow-derived macrophages (BMDMs). Moreover, Nox4 deficiency, but not Nox2/gp91phox and the cytosolic subunit p47phox, resulted in enhanced survival of the intracellular T. gondii RH strain and impaired expression of T. gondii-mediated MIF in BMDMs. Additionally, Nox4-deficient mice showed increased susceptibility to virulent RH strain infection and increased cyst burden in brain tissues and low levels of MIF expression following infection with the avirulent ME49 strain. Collectively, our findings indicate that Nox4-mediated ROS generation plays a central role in MIF production and resistance to T. gondii infection.

High-intensity focused ultrasound combined with hysteroscopic resection to treat retained placenta accreta.

We present a case of retained placenta accreta treated by high-intensity focused ultrasound (HIFU) ablation followed by hysteroscopic resection. The patient was diagnosed as submucosal myoma based on ultrasonography in local clinic. Pathologic examination of several pieces of tumor mass from the hysteroscopic procedure revealed necrotic chorionic villi with calcification. HIFU was performed using an ultrasound-guided HIFU tumor therapeutic system. The ultrasound machine had been used for real-time monitoring of the HIFU procedure. After HIFU treatment, no additional vaginal bleeding or complications were observed. A hysteroscopic resection was performed to remove ablated placental tissue 7 days later. No abnormal vaginal bleeding or discharge was seen after the procedure. The patient was stable postoperatively. We proposed HIFU and applied additional hysteroscopic resection for a safe and effective method for treating retained placenta accreta to prevent complications from the remaining placental tissue and to improve fertility options.

The effect of fibroblast growth factor on distinct differentiation potential of cord blood-derived unrestricted somatic stem cells and Wharton's jelly-derived mesenchymal stem/stromal cells.

BACKGROUND AIMS: Perinatal tissues are considered an attractive source of mesenchymal stem/stromal cells (MSCs) and have unique characteristics depending on their origin. In this study, we compared the basic characteristics of unrestricted somatic stem cells isolated from cord blood (CB-USSCs) and MSCs isolated from Wharton's jelly of umbilical cords (WJ-MSCs). We also evaluated the effect of basic fibroblast growth factor (bFGF) supplementation on the growth and differentiation of these cells. METHODS: CB-USSCs and WJ-MSCs were isolated from the same individual (n = 6), and their morphology, cell surface antigens, proliferation, expression of stemness markers and adipogenic, osteogenic and chondrogenic differentiation potentials were evaluated. Their morphology, proliferation and differentiation potentials were then also compared in the presence of bFGF supplementation (10 ng/mL). RESULTS: Overall, CB-USSCs expressed DLK-1 and negative for all the HOX gene markers. The expression of cell surface antigen CD90, growth capacity and adipogenic differential potential of CB-USSCs were lower than those of WJ-MSCs. WJ-MSCs showed higher growth capacity, but the expression of CD73 and CD105 and their osteogenic differentiation potential were lower than those of CB-USSCs. The spindle morphology of both CB-USSCs and WJ-MSCs and the growth and adipogenic differentiation of CB-USSCs were improved by bFGF supplementation. However, the bFGF supplement did not have any positive effect on the tri-lineage differentiation potentials of WJ-MSCs. CONCLUSIONS: CB-USSCs and WJ-MSCs each had distinct characteristics including different growth capacity, distinguishable cell surface markers and distinct adipogenic and osteogenic potentials. bFGF supplementation improved the growth capacity and adipogenic differentiation of CB-USSCs.

Characterization of two alkyl hydroperoxide reductase C homologs alkyl hydroperoxide reductase C_H1 and alkyl hydroperoxide reductase C_H2 in Bacillus subtilis.

AIM: To identify alkyl hydroperoxide reductase subunit C (AhpC) homologs in Bacillus subtilis (B. subtilis) and to characterize their structural and biochemical properties. AhpC is responsible for the detoxification of reactive oxygen species in bacteria. METHODS: Two AhpC homologs (AhpC_H1 and AhpC_H2) were identified by searching the B. subtilis database; these were then cloned and expressed in Escherichia coli. AhpC mutants carrying substitutions of catalytically important Cys residues (C37S, C47S, C166S, C37/47S, C37/166S, C47/166S, and C37/47/166S for AhpC_H1; C52S, C169S, and C52/169S for AhpC_H2) were obtained by site-directed mutagenesis and purified, and their structure-function relationship was analyzed. The B. subtilis ahpC genes were disrupted by the short flanking homology method, and the phenotypes of the resulting AhpC-deficient bacteria were examined. RESULTS: Comparative characterization of AhpC homologs indicates that AhpC_H1 contains an extra C37, which forms a disulfide bond with the peroxidatic C47, and behaves like an atypical 2-Cys AhpC, while AhpC_H2 functions like a typical 2-Cys AhpC. Tryptic digestion analysis demonstrated the presence of intramolecular Cys37-Cys47 linkage, which could be reduced by thioredoxin, resulting in the association of the dimer into higher-molecular-mass complexes. Peroxidase activity analysis of Cys→Ser mutants indicated that three Cys residues were involved in the catalysis. AhpC_H1 was resistant to inactivation by peroxide substrates, but had lower activity at physiological H2O2 concentrations compared to AhpC_H2, suggesting that in B. subtilis, the enzymes may be physiologically functional at different substrate concentrations. The exposure to organic peroxides induced AhpC_H1 expression, while AhpC_H1-deficient mutants exhibited growth retardation in the stationary phase, suggesting the role of AhpC_H1 as an antioxidant scavenger of lipid hydroperoxides and a stress-response factor in B. subtilis. CONCLUSION: AhpC_H1, a novel atypical 2-Cys AhpC, is functionally distinct from AhpC_H2, a typical 2-Cys AhpC.

Ultrasound-guided high-intensity focused ultrasound treatment for uterine fibroid & adenomyosis: A single center experience from the Republic of Korea.

OBJECTIVES: This study aimed to assess the therapeutic outcomes of patients with uterine fibroid or adenomyosis treated by ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation at Incheon Christian Hospital, Korea. METHODS: This study included 618 patients, of which 272 suffered from uterine fibroid and 346 suffered from adenomyosis. Treatment was administrated using the Model Haifu JC Focused Ultrasound Tumor Therapeutic System (Chongqing Haifu Technology, Chongqing, China) under real-time ultrasound guidance. A follow-up was conducted on volume change as well as on symptom improvement using the Symptom Severity Score (SSS) and Uterine Fibroid Symptom and Quality of Life (UFS-QOL) after treatment. RESULT: The uterine fibroid volume reduction rates (%) were 58.08%, 66.18%, and 77.59% at 3, 6, and 12 months after treatment, respectively. The SSS reduction rates (%) were 55.58%, 52.76%, and 50.39% by 3, 6, and 12 months, respectively. The UFS-QOL score increasing rates (%) were 42.66%, 43.50%, and 43.45% by 3, 6, and 12 months, respectively. The uterine volume reduction rates (%) for adenomyosis were 43.99%, 47.01%, and 53.98% by 3, 6, and 12 months, respectively. The SSS reduction rates (%) for adenomyosis were 55.61%, 52.38%, and 57.98% by 3, 6, and 12 months, respectively. The UFS-QOL score increasing rates (%) for adenomyosis UFS-QOL score were 80.06%, 69.39%, and 85.07% by 3, 6, and 12 months, respectively. CONCLUSION: We conclude that USgHIFU treatment for uterine fibroid and adenomyosis is an effective non-invasive therapy via the assessment of fibroid volume reduction, symptom improvement, UFS-QOL score increase, and acceptable level of side effects. Although preliminary experience of HIFU is encouraging, well-designed prospective trials and more clinical experiences are needed to ascertain the efficacy and safety of this new treatment.

Thioredoxin 1 as a serum marker for ovarian cancer and its use in combination with CA125 for improving the sensitivity of ovarian cancer diagnoses.

The serum levels of Trx1 in patients with ovarian cancer were significantly higher than those in normal persons and patients with non-cancer inflammatory diseases. The level of Trx1 increased with the Figo stage. Ovarian cancer patients who were determined to be negative for CA125, were observed to have serum Trx1 levels as high as those of CA125-positive patients. In addition, patients with non-cancer inflammatory diseases had lower plasma Trx1 1 levels than did controls, showing that Trx1 allows clear distinctions between ovarian cancer and these non-cancer diseases. Combinational analysis of CA125 with Trx1 for the detection of ovarian cancer suggests that the diagnostic capacity of CA125 alone for the early detection of ovarian cancer, especially regarding sensitivity, is significantly improved by its combination with Trx1. Taken together, we conclude that serum Trx1 is useful for the early diagnosis of ovarian cancer.

Thioredoxin 1 as a serum marker for breast cancer and its use in combination with CEA or CA15-3 for improving the sensitivity of breast cancer diagnoses.

BACKGROUND: The human cytosolic thioredoxin (Trx) contains a redox-active dithiol moiety in its conserved active-site sequence. Activation by a wide variety of stimuli leads to secretion of this cytoplasmic protein. Function of Trx1 has been implicated in regulating cell proliferation, differentiation, and apoptosis. The aim of this study was to assess the clinical significance of serum Trx1 level in patients with breast carcinoma. RESULTS: To clarify whether serum levels of Trx1 could be a serum marker for breast carcinoma, we measured the serum levels of Trx1 in patients with various carcinomas (breast, lung, colorectal, and kidney cancers) using an ELISA, and investigated its associations with the tumour grading from I to III. At the cut-off point 33.1725 ng/ml on the receiver operating characteristic curve (ROC) Trx1 could well discriminate breast carcinoma from normal controls with a sensitivity of 89.8%, specificity 78.0%, and area under the ROC (AUC) 0.901 ± 0.0252. The serum level was well correlated with the progress of the breast carcinoma. We also investigated the diagnostic capacity of CEA and CA15-3 for the early detection of metastatic breast cancer comparing that of Trx1. In contrast to the serum CEA and CA15-3 tumour markers, the serum Trx1 levels of the early cancer (grade I) patients were significantly higher than those of normal control subjects, showing a high diagnostic sensitivity and selectivity (89.4% sensitivity, and 72.0% specificity). The serum levels of Trx1 in various patients with lung, colorectal, and kidney carcinomas indicate that the level of Trx1 is significantly higher than those of other cancer patients. Combinational analysis of CEA or CA15-3 with Trx1 for the detection of breast cancer suggest that the diagnostic capacity of CEA or CA15-3 alone for the early detection of breast cancer, especially regarding sensitivity, is significantly improved by its combination with Trx1. CONCLUSIONS: Taken together, we conclude that serum Trx1 is useful for the early diagnosis of breast cancer or the early prediction prognosis of breast cancer, and therefore has a valuable use as a diagnostic marker and companion marker to CEA and CA15-3 for breast cancer.

Single-port laparoscopic salpingectomy for surgical treatment of tubal pregnancy: comparison with multi-port laparoscopic salpingectomy.

BACKGROUND: This study investigates the safety and feasibility of transumbilical single-port laparoscopic salpingectomy (SPLS) using conventional laparoscopic instruments compared to conventional multi-port laparoscopic salpingectomy (MPLS) for surgical treatment of tubal pregnancy. MATERIAL AND METHODS: We conducted a retrospective analysis of 63 patients with tubal pregnancy who underwent SPLS and 71 patients who underwent conventional MPLS between January 2008 and December 2010. All patients in the SPLS group had a drainage tube placed through the umbilicus, and, in the MPLS group, through a 5-mm trocar site in one side of the lower abdomen. RESULTS: No significance difference was discovered between the groups with regard to adjusted hemoglobin values (SPLS, 1.9 ± 1.0 g/dL versus MPLS, 1.7 ± 1.0 g/dL, P = 0.335). Additionally, there was also no significant difference in clinical characteristics, intraoperative findings, or operative outcomes. CONCLUSIONS: Our study demonstrated that transumbilical SPLS using conventional laparoscopic instruments has operative outcomes comparable to MPLS for the surgical treatment of tubal pregnancy. Transumbilical SPLS may therefore be offered as a feasible alternative to MPLS.

Transumbilical single port laparoscopic surgery for the treatment of concomitant disease.

BACKGROUND: We report our experience of transumbilical single port laparoscopic surgery (TUSPLS) for multiple concomitant intraabdominal pathologies, and assess the feasibility of this technique with several technical tips. METHODS: Various combined procedures using TUSPLS were performed since April, 2008. All records of concomitant laparoscopic procedures using TUSPLS were searched at three hospitals. RESULTS: Forty-one patients underwent 82 combined procedures using TUSPLS in a single session. The perioperative outcomes of simultaneously performed cholecystectomy and ovarian cystectomy using TUSPLS (n = 14) are compared with those of using CLS (n = 11). The operating time was significantly longer with the TUSPLS method than with the CLS method. However, postoperative convalescent outcomes such as postoperative hospital stay, VAS pain score, and required analgesics showed no differences between the two methods. Also, there were no significant operative complications associated with the two methods. Fewer trocars were used with the TUSPLS method. CONCLUSIONS: Combined laparoscopic procedures for various concomitant pathologies in the abdomen can be performed using transumbilical single port laparoscopic surgery without increasing morbidity or hospital stay in patients with acceptable risk.

Effectiveness of a culturally integrated liver cancer education in improving HBV knowledge among Asian Americans.

OBJECTIVE: The aim of this study was to assess the effectiveness of a hepatitis B virus (HBV) educational program in increasing HBV knowledge. METHODS: Using a cluster randomized control trial to recruit participants from the community-based organization in the Baltimore-Washington Metropolitan Area; a total of 877 Asian American participants completed a self-administered pretest. HBV knowledge was the outcome measure. The intervention group received a 30-minute educational program. After the educational program, the intervention group completed a post-education survey. Six months after the education, all participants were followed by phone. RESULTS: The intervention group showed significantly higher knowledge scores than the control group at the 6-month follow-up (between-group difference was 1.44 for knowledge of transmission modes and 0.59 for sequelae, p < 0.01). For the intervention group, the increase in knowledge of HBV transmission modes in post-education was much higher than that at the 6-month follow-up (4.18 vs. 2.07), p < 0.01) compared to baseline. Age was also an important factor on the educational effect: Those older than 60 years reported the lowest scores in all three points. CONCLUSIONS: Findings suggest that this culturally integrated liver cancer educational program increased HBV knowledge. Differential strategies are needed to target age groups, separately educating those younger and those older.

Outcomes and prognostic factors of cervical cancer after concurrent chemoradiation.

AIM: Concurrent chemoradiation (CCRT) is the standard treatment for locally advanced cervical cancer. This study was undertaken to evaluate the outcomes and the prognostic factors for cervical cancer after CCRT. MATERIAL AND METHODS: The medical records of 174 patients with International Federation of Gynecology and Obstetrics stage IB1-IVA who were treated at three affiliated hospitals of the Catholic University of Korea between January 1999 and December 2008 were reviewed and analyzed. Patients received pelvic radiotherapy with one of three regimens of cisplatin-based chemotherapy concurrently and high-dose rate brachytherapy. The radiation field was extended to include para-aortic lymph nodes, if necessary. RESULTS: The median follow-up period was 29.5 months (range, 5-96 months). Using multivariate analysis, stage (P = 0.014), tumor size (P = 0.043), and clinical response (P = 0.001) had a significant effect on overall survival. Similarly, progression-free survival (PFS) was influenced by stage (P = 0.004), tumor size (P = 0.02), clinical response (P = 0.011), and normalized squamous cell carcinoma antigen level after CCRT (P = 0.007). The 5-year survival rates were 91.7% (standard error, 5.8%) for stages IB1-IIA, 71.5% (standard error, 7.8%) for stage IIB, 44.9% (standard error, 7.8%) for stage III, and 20.9% (standard error, 12.0%) for stage IVA. A total of 151 out of 174 patients (86.8%) completed the planned treatment. Toxicities were manageable with supportive therapy. CONCLUSIONS: Cisplatin-based CCRT is well-tolerated. Good clinical response revealed a favorable correlation to survival. A maximal effort to achieve this goal might prolong survival in patients with cervical cancer.

Disseminated peritoneal leiomyomatosis after hysterectomy: a case report.

BACKGROUND: Disseminated peritoneal leiomyomatosis (DPL) is a rare disease characterized by multiple benign leiomyomas arising in the pelvic and abdominal cavities in women. DPL is observed particularly in reproductive age groups and often mimics carcinomatosis grossly, but with benign histology and a favorable prognosis. The possible causes could be divided into hormonal, subperitoneal mesenchymal stem cells, metaplasia, genetic or iatrogenic after morcellation of myoma during laparoscopic surgery. Management includes surgery followed by adjuvant hormonal therapy, systemic chemotherapy or aromatase inhibitor treatment in cases of nonresectable disease. CASE: We report a case of DPL occurring after 2 previous operations including myomectomy and hysterectomy. After the DPL operation, the patient was treated with a gonadotropin-releasing hormone agonist for 6 months. One year after surgery, image analysis showed no evidence of disease. CONCLUSION: This rare condition must be considered even when a patient presents with abdominal masses after myomectomy followed by hysterectomy.

Single-port laparoscopic cornual resection for a spontaneous cornual ectopic pregnancy following ipsilateral salpingectomy.

OBJECTIVE: To describe the single-port laparoscopic management of a spontaneous cornual ectopic pregnancy following ipsilateral salpingectomy. DESIGN: Case report and technique description. SETTING: University hospital. PATIENT(S): A 28-year-old woman with a spontaneous cornual pregnancy of 5 weeks' gestation following previous ipsilateral salpingectomy. INTERVENTION(S): Single-port laparoscopic cornual resection (surgeon, Y.-W.K.). MAIN OUTCOME MEASURE(S): Serum ß-hCG levels. RESULT(S): Complete resolution of cornual pregnancy. CONCLUSION(S): We performed a successful single-port laparoscopic cornual resection for a spontaneous cornual ectopic pregnancy following ipsilateral salpingectomy.

Brain metastasis from uterine cervical cancer.

Uterine cervical cancer usually spreads by local extension and through the rich lymphatic network to the retroperitoneal lymph nodes. However, brain metastasis from primary cervical cancer is extremely rare. They are usually seen late in the clinical course and have poor prognosis. We present a 48-year-old woman with squamous cell carcinoma of the cervix who developed multiple brain metastases after 30-month treatment of the primary disease. The patient received whole brain radiation therapy and steroids, and she is alive without any neurologic symptoms and signs at the 6-month follow-up after treatment of the recurrence.

Can intraoperative motor-evoked potentials predict all the spinal cord ischemia during moderate hypothermic beating heart descending thoracic or thoraco-abdominal aortic surgery?

BACKGROUND AND AIM OF THE STUDY: Paraplegia is a serious complication of descending thoracic or thoraco-abdominal aortic aneurysm (DTAA or TAAA, respectively) surgery. The functional integrity of the spinal cord can be monitored with intraoperative motor-evoked potentials (MEPs). Herein, we evaluated the results and adequacy of MEP monitoring. METHODS AND RESULTS: Between March 2006 and April 2009, 33 patients (24 males and 9 females) were monitored with MEPs and reviewed retrospectively. The mean age was 50.7 ± 15.2 years. Eighteen and 15 patients underwent TAAA and DTAA repairs, respectively. We routinely used femoro-femoral partial bypass and cerebrospinal fluid (CSF) drainage. If the MEP demonstrated a significant change, prompt protective interventions were performed. During the procedure, 31 patients (93.9%) had a detectable MEP, of whom four had significant MEP changes and only one had an accompanying alteration in the somatosensory-evoked potential. In-hospital mortality occurred in two patients (6.0%) because of mesenteric ischemia and sepsis, respectively. Postoperative paraplegia developed in two patients (6.0%), one with an undetectable MEP and another with no significant intraoperative MEP change. Both patients had hypotensive events and impaired CSF drainage in the immediate postoperative period. Permanent paraplegia persisted in one patient. In four patients with intraoperative MEP changes, paraplegia did not occur. CONCLUSIONS: Although intraoperative monitoring of MEP has been shown to be effective in detecting cord ischemia during DTAA or TAAA surgery, it is not definitive and cannot predict all neurologic deficits. Other postoperative preventive strategies such as CSF drainage and maintaining a high blood pressure are important to prevent paraplegia.

Single-port laparoscopic myomectomy using a new single-port transumbilical morcellation system: initial clinical study.

STUDY OBJECTIVE: To evaluate the feasibility of single-port laparoscopic myomectomy with transumbilical morcellation and suturing. DESIGN: Continuing prospective study (Canadian Task Force classification II-3). SETTING: University hospital. PATIENTS: Fifteen patients who underwent single-port laparoscopic myomectomy between September 2008 and October 2009 to remove single or multiple uterine myomas, at least 1 in each patient measuring greater than 4 cm in diameter. INTERVENTIONS: All single-port laparoscopic myomectomy procedures were performed by a single surgeon (Dr. Y.W. Kim). Myomas were extracted transumbilically by cutting the myomas into smaller pieces with a knife or a conventional electromechanical morcellator. After making a single 1.5- to 2.0-cm umbilical incision, the single-port system, created with a wound retractor and a surgical glove, was inserted. All operations were performed using conventional rigid straight laparoscopic instruments. Laparoscopic suturing was performed in intramural myomas and some subserosal myomas. MEASUREMENTS AND MAIN RESULTS: Patient mean (SD; range) age was 38.3 (5.6; 29-49) years. The number of myomas per patient was 1.6 (1.4; 1-6). The diameter of the largest myomas was 6.1 (1.5; 4.2-9.6) cm. In 4 patients, only a knife was required for transumbilical extraction of myomas, and in 11 patients, transumbilical morcellation with an electromechanical morcellator with or without a knife was used. Transumbilical drainage tubes were inserted into the pelvic cavity in 11 of 15 patients. Operative time was 96.7 (33.8; 35-150) minutes. The decrease in postoperative hemoglobin concentration was 1.8 (1.2; 0.4-3.6) g/dL. During the operations, no patients required blood transfusion. No patients developed postoperative fever. Neither bowel injury nor urinary tract injury occurred in any patient. The postoperative hospital stay was 3.1 (0.8; 2-4) days. CONCLUSION: Single-port transumbilical morcellation using a conventional electromechanical morcellator with or without a knife is feasible. Single-port laparoscopic myomectomy is an alternative method with cosmetic advantage.

Urethral prolapse in a premenarchal Asian girl.

BACKGROUND: Urethral prolapse is an uncommon condition characterized by complete circular eversion of the urethral mucosa through the external meatus. CASE: We present the case of a 9-year-old Asian girl who presented with 3 days of vaginal spotting and a painless vulvar mass. After several unsuccessful attempts of manual reduction, surgery was performed. As a result, the patient had no recurrence or meatal stenosis at the 6-month follow-up. CONCLUSION: Urethral prolapse can be clinically diagnosed without laboratory or radiographic evaluation by demonstrating edematous tissue that surrounds the meatus circumferentially. It should not be confused with other causes of vaginal bleeding, including sexual abuse.