A randomized comparison of training programs using a pelvic model designed to enhance pelvic floor examination in patients presenting with chronic pelvic pain.

INTRODUCTION: Pelvic floor myalgia is a common cause and contributor to chronic pelvic pain [Neurourol Urodyn 4:984-1008 (2017)]. The purpose of this study was to compare in-person versus video-based teaching methods of a comprehensive assessment of the pelvic floor musculature on a pelvic model. METHODS: A randomized controlled trial of 46 participants was conducted. The participants were randomized into two groups. Both groups were taught by the same pelvic floor physiotherapist using two different teaching methods on a pelvic model. Group 1 watched an instructional video, whereas group 2 had in-person training. Both groups underwent pre- and post-training assessments consisting of a written examination and an Objective Structured Clinical Examination (OSCE). Primary outcome measure was the change in participants' pre- and post-training assessment scores. Secondary outcome measures were perceived changes in both participants' comfort level in performing pelvic floor examination and applicability of the training program to clinical practice. RESULTS: There was no statistically significant difference between the teaching methods in the degree of improvement of the participants' mean written assessment scores (p = 0.58), OSCE scores (p = 0.15), and perceived comfort level (p = 0.19). Participants' mean pre- and post-assessment scores improved significantly (p < 0.001). Participants reported the training program to be applicable towards their clinical practice. CONCLUSIONS: This study demonstrates that learners' assessment of pelvic floor musculature can be enhanced using varied teaching methods on a pelvic model.

Does Essure Cause Significant De Novo Pain? A Retrospective Review of Indications for Second Surgeries After Essure Placement.

STUDY OBJECTIVES: To examine the surgical indications and pathologic findings in patients undergoing a second surgery after placement of the Essure permanent birth control system to determine the role of Essure in developing new-onset pelvic pain. DESIGN: Retrospective cohort (Canadian Task Force classification II-2). SETTING: Tertiary-level hospital. PATIENTS: Women who have had Essure placement and subsequent second surgery. INTERVENTION: Charts from women undergoing pelvic surgery after Essure placement from June 2002 to June 2013 were reviewed and the indication for the procedure, surgical and pathologic findings noted. MEASUREMENTS AND MAIN RESULTS: Of 1430 patients, 62 (4.3%) had a second surgery after Essure placement, and 24 of these (1.6%) had a surgical indication not related to pain. The remaining 38 patients (2.7%) had either new-onset (n = 27) or worsening pre-existing pain (n = 11). In the new-onset pain group, 15 (1%) had surgical findings or pathology consistent with a painful gynecologic condition. In the remaining 12, 8 (0.5%) seemed to be related to some perforation or migration of the Essure device. In 4 patients (0.3%) with no other obvious cause for the new-onset pain, it was thus attributed to the Essure microinsert. CONCLUSION: Essure sterilization can be associated with new-onset pain or a worsening of a pre-existing painful gynecologic condition, although both are very rare. A careful and complete consent before placement and a thorough examination if pain does occur usually show some etiology for the pain other than the Essure insert.

Oral analgesia vs intravenous conscious sedation during Essure Micro-Insert sterilization procedure: randomized, double-blind, controlled trial.

STUDY OBJECTIVE: To compare the pain reported by patients during the Essure Micro-Insert sterilization procedure using either intravenous conscious sedation or oral analgesia. DESIGN: Randomized, double-blind, placebo-controlled trial (Canadian Task Force classification I). SETTING: Tertiary care ambulatory women's clinic. PATIENTS: Eighty women of reproductive age women requesting permanent sterilization. INTERVENTION: Hysteroscopic placement of the Essure Micro-Insert permanent birth control system. MEASUREMENTS AND MAIN RESULTS: Patients undergoing placement of the Essure Micro-Insert system for permanent contraception were randomized to receive either intravenous conscious sedation, oral analgesia, or placebo. During the procedure, pain scores were recorded using a visual analog scale. Patients in the oral analgesia group reported slightly more pain during insertion of the hysteroscope and placement of the second micro-insert; the groups were otherwise equivalent. They were also equivalent when all visual analog scale scores were combined. CONCLUSION: Oral analgesia is an effective method of pain control during placement of the Essure Micro-Insert permanent birth control system.

Pentoxifylline after conservative surgery for endometriosis: a randomized, controlled trial.

STUDY OBJECTIVE: To compare outcomes after conservative surgery for endometriosis with and without pentoxifylline and to assess the efficacy of pentoxifylline in preventing recurrence of endometriosis after conservative surgery. DESIGN: Parallel-group, randomized, controlled trial (Canadian Task Force classification I). SETTING: Tertiary care hospital. PATIENTS: Women undergoing conservative surgery for endometriosis. INTERVENTIONS: Laparoscopic conservative surgery for endometriosis was completed by a single surgeon (J.A.T.), and all suspected endometriotic lesions were widely excised using monopolar coagulation and scissors. All specimens were submitted to pathology for confirmation of the diagnosis. Randomization to the treatment or control groups was completed preoperatively in the outpatient surgery unit by drawing colored marbles. A preoperative visual analog pain scale (VAS) was completed. After surgery, patients were discharged home with prescriptions for naproxen, hydromorphone, and pentoxifylline. MEASUREMENTS AND MAIN RESULTS: Visual analog scale scoring was completed monthly by each patient, and each patient was seen monthly for review and pelvic examination. Analgesic use was recorded daily using an individual medication log. Ongoing treatment choice after completion of the 3-month follow-up was recorded. The relationship between the group receiving pentoxifylline and the control group as well as analysis of the VAS scores at time of surgery and 1, 2, and 3 months postoperatively was determined using a covariate mixed-model ANOVA. Forty-nine patients were enrolled in the trial. One patient became pregnant before surgery, and 1 patient's chart was not available for analysis. Of the 47 who underwent conservative surgery for endometriosis, 9 (19%) had no endometriosis noted in the pathology specimens submitted. Two patients withdrew from the trial after surgery, and 2 patients were lost to follow-up after relocating to a different city. Nineteen women completed the 3-month follow-up in the control group, 15 in the group receiving pentoxifylline. The mean age, gravidity, parity, body mass index, previous surgery for endometriosis, menstrual cycle, and preoperative analgesic use did not differ significantly between the control and treatment groups. The time to complete the conservative surgery did not vary between the 2 groups. There were no intraoperative complications: two patients were admitted postoperatively, one for nausea and vomiting, one for pain that resolved 24 hours after admission. The VAS scores did not differ at the time of surgery; and in both the control and the pentoxifylline groups, there was significant improvement at each monthly interval (p <.05). The patients receiving pentoxifylline had significantly better VAS scores at 2 and 3 months after surgery (p <.03). CONCLUSIONS: The use of pentoxifylline after conservative surgery for endometriosis resulted in improved VAS scores at 2 and 3 months after the procedure when compared with patients having conservative surgery only. The longer-term use of pentoxifylline after conservative surgery may improve long-term outcomes after surgical treatment for endometriosis.

Assessment of costs associated with outpatient total laparoscopic hysterectom.

OBJECTIVE: To assess the costs associated with the performance of outpatient total laparoscopic hysterectomy. METHODS: This was a retrospective cohort study involving 224 consecutive patients undergoing total laparoscopic hysterectomy (TLH) by a single surgeon in the Regina General Hospital. Outcomes included costs associated with the initial procedure as well as those associated with any intraoperative or postoperative complications. RESULTS: The mean age of the patients was 42.7 years. The mean uterine weight was 205 grams (range 69-1163 g), the mean operating time was 79 minutes, and the mean blood loss was 89 cc. The mean postoperative stay in the day surgery unit (DSU) was 354 minutes. Ten patients required admission from the DSU, and nine patients were admitted more than 24 hours after surgery. The total number of admission days was 24, which cost 21,900 US dollars. The total cost of all disposables was 127,373 US dollars and the cost associated with the stays in day surgery was 89,600 US dollars. The total cost for the 224 TLH procedures was 238,573 US dollars, and the average cost per TLH was 1065 US dollars. CONCLUSION: Outpatient TLH can be completed safely and with costs that are lower than those incurred by patients having short-stay vaginal hysterectomy in our institution. Outpatient TLH offers the opportunity to save health care costs and a procedure with excellent results.

Neuroprotection following fluid percussion brain trauma: a pilot study using quercetin.

Previously, we were able to demonstrate the neuroprotective effect of quercetin in an animal model of acute traumatic spinal cord injury. The objective of the present study was to determine whether any neuroprotective effect is seen when quercetin is administered in an animal model of traumatic brain injury. Twenty-six adult male Sprague-Dawley rats were submitted to moderate fluid percussion injury in the anterior midline position. Animals were divided into two experimental groups: one group received 25 mumol/kg quercetin starting 1 h after injury, while animals in the second group received saline vehicle (n = 13 per group). Eight animals were used as uninjured healthy controls. Eight animals in each experimental group were sacrificed at 24 h, while five animals per group were allowed to recover for 72 h following injury. Compound action potential amplitudes (CAPAs) were recorded on 400-microm vibrotome sections of the corpus callosum superfused with oxygenated artificial CSF (n = 3 per animal) in 20 experimental animals and five healthy controls. Three brains from animals in each experimental group and healthy controls were used for histological, immunocytochemical and biochemical analysis after sacrifice at 24 h. CAPAs in uninjured animals had a mean of 1.12 mV. This decreased to 0.55 mV in saline vehicle-treated injured animals by 24 h and changed little over the next 3 days. CAPAs were significantly better at 0.82 mV at 24 h and 0.76 mV at 3 days in quercetin-treated injured animals when compared to injured saline vehicle controls. Quercetin significantly prevented decrease of glutathione levels and decreased myeloperoxidase activity. We conclude that this dietary flavonoid has therapeutic potential following brain trauma.

Hypercholesterolemia-induced long-term increase of macrophages in the myocardium of New Zealand White rabbits.

The effect of hypercholesterolemia on the number, immunological phenotype and oxidative stress-dependent processes of macrophages (MPhi) and dendritic cells (DC) was studied in New Zealand White rabbits. The left ventricular myocardium was immunohistochemically analyzed in group I (control), which was on standard chow, and groups II and III, which both received a 0.5% cholesterol-enriched diet for 96 days, but thereafter, only group III was fed standard chow for 4 months. In the myocardial interstitium of group I, (1) significantly less RAM-11-immunoreactive (ir) MPhi than S-100-ir DC were found; (2) both, MPhi and DC, were similar major histocompatibility complex (MHC) class II molecules LN3-, ISCR3-, and 2.06-ir; (3) all MPhi and most DC were manganese superoxide dismutase (MnSOD)-ir and homing receptor CD44-ir. In group II, only MPhi increased about 10-fold in the myocardium in parallel to the about 40-fold increase of the serum cholesterol levels. In group III, the elevated serum cholesterol levels significantly decreased (about 90%), while the MPhi still remained significantly increased (about 8-fold). The cellular immunoreactivities of MHC class II molecules, as well as MnSOD and CD44 did not change in groups II and III in comparison to group I. We suggest that mainly the MPhi, which increase within the myocardium of rabbits after elevation of serum cholesterol levels and remain significantly increased for a long time after decrease of the blood lipid levels, might initiate or aggravate eventual complications such as coronary atherosclerosis and myocardial fibrosis.

Tumour necrosis factor-alpha (TNF-alpha) transgene-expressing dendritic cells (DCs) undergo augmented cellular maturation and induce more robust T-cell activation and anti-tumour immunity than DCs generated in recombinant TNF-alpha.

Tumour antigen presentation by dendritic cells (DCs) to T cells in lymphoid organs is crucial for induction of anti-tumour immune responses. It has been previously reported that tumour necrosis factor-alpha (TNF-alpha) is required for DC activation and subsequent induction of optimal immune responses, and thus DCs for anti-tumour vaccination are often generated by culture in exogenous TNF-alpha. In the present study, we investigated the effect on anti-tumour immunity of vaccination with Mut1 tumour peptide-pulsed DCs engineered to express a TNF-alpha transgene. Our data shows that transfection of DCs with recombinant adenovirus AdV-TNF-alpha resulted in greater maturation of the DCs than occurred with control DCs cultured in exogenous TNF-alpha, as determined by up-regulated expression of pro-inflammatory cytokines (e.g. interleukins 1beta and 18), chemokines [e.g. interferon-gamma-inducible protein-10 and macrophage inflammatory protein-1beta (MIP-1beta)], the CC chemokine receptor CCR7, and immunologically important cell surface molecules (CD40, CD86 and intercellular adhesion molecule-1). These transgenic DCs stimulated stronger allogeneic T-cell responses in vitro and T-cell activation in vivo; displayed 2.4-fold enhanced chemotactic responses to the MIP-3betain vitro (P<0.05); and, perhaps most importantly, trafficked into the draining lymph nodes dramatically (seven-fold, P<0.01) more efficiently than the control DCs. Our data also demonstrate that vaccination of mice with Mut1 peptide-pulsed, AdV-TNF-alpha-transfected DCs stimulated more efficient in vitro Mut1-specific CD8+ cytotoxic T-cell responses and solid tumour immunity in vivo, when compared to the in vitro TNF-alpha-cultivated DCs. Thus, DCs engineered to secrete TNF-alpha may offer a new strategy in DC cancer vaccines.