Prognostic significance, angiographic characteristics and impact of antithrombotic and anticoagulant therapy on outcomes in high versus low grade coronary artery ectasia: A long-term follow-up study.

OBJECTIVES: To assess the prognostic significance of high vs. low grade coronary artery ectasia (CAE) and the impact of antithrombotic or anticoagulant therapy on adverse cardiac outcomes. BACKGROUND: There is paucity of knowledge on the impact of angiographic characteristics in CAE or that of antithrombotic or anticoagulant therapy on outcomes. METHODS AND RESULTS: In this retrospective study, we reviewed angiograms and medical records of all cases of confirmed CAE (2001-2011). Extent of CAE was categorized using the Markis classification. Types 1 and 2 were categorized as high-grade and types 3 and 4 as low-grade CAE. Angiographic flow was recorded as normal or sluggish (

One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals.

BACKGROUND: Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations. AIM: To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery. METHODS: During a period of 9 years (2007-2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons. OUTCOMES: Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS. RESULTS: Mean follow-up was 44 months (range = 10-92). Mean surgery time was 270 minutes (range = 215-325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient. CLINICAL IMPLICATIONS: Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates. STRENGTHS AND LIMITATIONS: To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure. CONCLUSIONS: Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries. Stojanovic B, Bizic M, Bencic M, et al. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-746.

Intravenous Adenosine Infusion is Safe and Well Tolerated During Coronary Fractional Flow Reserve Assessment in Elderly Patients With Severe Aortic Stenosis.

BACKGROUND: This study assessed the safety of intravenous adenosine infusion during fractional flow reserve (FFR) evaluation of intermediate coronary lesions in severe aortic stenosis (AS). In severe AS, the extent of underlying coronary artery disease (CAD) can be an important determinant for deciding between surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). Hemodynamic assessment of coronary lesion severity using FFR may reduce the extent of revascularization needed and make TAVR more feasible in higher-risk patients (compared with coronary artery bypass surgery with SAVR). METHODS AND RESULTS: We retrospectively analyzed the demographic, clinical, and hemodynamic parameters of 72 patients with severe AS who underwent FFR procedure with intravenous adenosine infusion for hemodynamic assessment of intermediate coronary artery lesions. Severe AS patients were elderly, predominantly male, and had a high prevalence of peripheral arterial disease, prior myocardial infarction, left ventricular hypertrophy, and chronic kidney disease. Mean aortic valve area in these patients was 0.71 ± 0.24 cm². No patient with severe AS required discontinuation of the adenosine and all patients tolerated the infusion well. We observed a statistically significant reduction in systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) during adenosine infusion compared with the baseline values. However, no clinically significant adverse events occurred. CONCLUSION: In elderly patients with severe AS, adenosine infusion is safe and well tolerated during FFR evaluation of intermediate coronary lesions. There was a significantly greater drop in SBP, DBP, MAP, and HR with adenosine infusion as compared with baseline values. This, however, was not associated with clinically significant adverse events.

An overview of neovaginal reconstruction options in male to female transsexuals.

Transsexualism is a complex condition in which the person experiences the inconsistency between the desired gender and their biological gender. Absence of the vagina is devastating in male to female transsexuals. Creation of the neovagina is the main surgical problem in these patients. Historically, beginnings of the neovaginal creation have their roots in the treatment of Mayer-Rokitansky syndrome and conditions such as cloacal anomalies, certain intersex disorders, vaginal malignancies, or severe vaginal trauma, but have more recently found great purpose in male to female sex reassignment surgery. Many operative procedures have been described but none is ideal. Therefore, the search for new, improved solutions continues. In neovaginoplasty reconstruction of the vulvovaginal complex is performed in its entity. The gold standard in neovaginal reconstruction in male to female sex reassignment surgery is penile skin inversion technique with or without scrotal flaps, which enables adequate sensation of the neovagina, good neovaginal depth, good erotic sensitivity of the neclitoris, and esthetically acceptable labia minora and maiora.

Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases.

INTRODUCTION: There are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue. AIM: To evaluate the anatomical and functional results of sigmoid vaginoplasty and long-term sexual and psychological outcomes in 86 patients with vaginal absence. METHODS: Between April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis. Main Outcome Measures. Sexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires. RESULTS: Follow-up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23%). CONCLUSIONS: Rectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery.

Rectosigmoid vaginoplasty in patients with vaginal agenesis: sexual and psychosocial outcomes.

BACKGROUND: The main goal in women with Mayer-Rokitansky-Küster-Hauser syndrome (vaginal agenesis) is creation of a neovagina that will satisfy the patient's desire. We evaluated sexual and psychosocial adjustment in patients who underwent rectosigmoid vaginoplasty because of vaginal agenesis. METHODS: A total of 36 women, aged 21 to 38 years (mean=26) who underwent rectosigmoid vaginoplasty from 1997 to 2006 were evaluated. Sexual and psychosocial appraisal included the Female Sexual Function Index (FSFI), Beck's Depression Inventory (BDI), and standardised questionnaires about postoperative satisfaction, social and sexual adjustment. RESULTS: Mean FSFI score was 28.9 (range=11.5-35.7) with a cut-off score of 26.55 for sexual dysfunction. Out of the 36 women, 10 (27, 8%) had sexual dysfunction. Mean BDI score was 7.55 (cut-off score=0-9 for non-depression). Twenty-eight women (77.8%) were without symptoms of depression, six women (BDI range=10-29) had moderate and two women had severe depression (BDI=42). There were a significant number of patients (P<0.01) with a high satisfaction score in FSFI and low BDI results. Thirty-two (88.9%) of the patients believed that surgery was done at the right time and the main postoperative support came from their family. Thirty-four (94.4%) of the patients reported satisfactory femininity, with a heterosexual orientation. Thirty patients (83. 3%) were very satisfied with the surgery, while 34 considered surgery as the best treatment. CONCLUSIONS: The sexual function and psychosocial status of these patients should be followed long-term to estimate their quality of life.

[Repair of vesicovaginal fistula caused by radiation therapy with labia maiora skin flap].

INTRODUCTION: Vesicovaginal fistula can occur after delivery, gynaecologic or urologic surgery, irradiation therapy or as destruction caused by a tumour or trauma. The main problem after irradiation is decreased elasticity of the tissue around the fistula. We present our experience in the treatment of three patients with vesicovaginal fistula using a labia maiora skin flap. CASE OUTLINE: From May 2007 to January 2008 three patients with vesicovaginal fistula were treated using labia maiora skin flap. The fistulae occurred after mean 19 months (11, 20 and 26 months) following irradiation therapy applied to treat malignant disease. The mean age of the patients was 54 years (47, 53 and 62 years). The mean diameter of the fistulae was 3.5 cm (2, 4 and 4.5 cm). Using transvaginal approch, all devitalized and fibrous tissue was removed with the closure of the bladder wall. The labia maiora skin flap with good vascularization was transposed to close the defect and anastomozed to the vagina. The mean follow-up was 16 months (13, 17 and 18 months). Labia maiora skin flap size was mean 3.7 cm (2.6, 3.7 and 4.8 cm). We achieved satisfactory outcome in all patients. There were neither postoperative complications nor fistula recurrence. CONCLUSION: Labia maiora skin flap presents a good alternative for surgical treatment of vesicovaginal fistula. The flap is more adequate for larger defects and for the repair of fibrously changed vaginal wall which is present after irradiation therapy.

Are local clinical guidelines useful in promoting rational use of antibiotic prophylaxis in caesarean delivery?

OBJECTIVES: To identify changes in prescribing patterns of antibiotic prophylaxis in caesarean delivery after introduction of local clinical guidelines. To identify changes in outcomes of prescribing antibiotics following the implementation of local clinical guidelines on antibiotic prophylaxis. SETTING: University of Belgrade, Medical School, Clinic of Gynaecology and Obstetrics "Narodni front" Belgrade, Serbia. METHOD: A quantitative retrospective analysis of antibiotic use before (January-June 2005), and following (January-June 2006) implementation of guidelines on antibiotic prophylaxis in two wards. Patients who underwent caesarean section prior to (261) and following (281) introduction of local guidelines, participated in this study. MAIN OUTCOME MEASURES: Drug utilization cost presented as the number of DDD/100 bed days/eur, the average duration of hospital stay, number of wound infections. RESULTS: There was a significant change in prescribing patterns of antibiotic prophylaxis in caesarean section following introduction of local guidelines. The use of ceftriaxone, amikacin and metronidazole decreased (57.47% vs. 11.74%; 9.19% vs. 4.27%; 61.69% vs. 46.26%, respectively). On the other hand, the use of "older" antibiotics such as gentamicin, cefuroxime, cefazolin and ampicillin increased (14.56% vs. 29.18%; 9.2% vs. 17.44%; 9.58% vs. 45.2% and 0% vs. 3.9%, respectively). DDD/100 bed days/eur analysis revealed a 47% decrease of total cost for prophylactic antibiotic treatment in caesarean section following local guideline implementation. In contrast, rate of wound infections and duration of hospital stay were not significantly different in both groups. CONCLUSION: In an attempt to ensure cost-effective prophylactic use of antibiotics in caesarean delivery, local clinical guidelines were introduced. They resulted in changes in prescribing patterns of antibiotics. There was a significant decrease in use of 'third' generation of cephalosporin's whereas the use of "older" antibiotics with proven efficacy and safety increased. In contrast, there was no significant change in treatment outcomes such as wound infection and average hospital stay.

Intrauterine treatment of large fetal neck lymphangioma with OK-432.

Lymphangiomas are benign vascular malformations of the lymphatic system and most commonly present in the neck area. Large lymphangiomas may compress and/or displace the larynx, trachea and esophagus and cause serious respiratory and feeding problems in neonates. Prenatal therapy could eliminate the risks of the mentioned complications. Prenatal therapy may include the EXIT (ex utero intrapartum treatment) procedure. As this procedure has certain risks for both the neonate and mother, the introduction of a safer method is justified. The use of OK-432, as a sclerosing agent, has shown positive results in several published cases of cystic hygroma, but there is no study about the prenatal use of this agent in the treatment of lymphangioma. The aim of this study was to present our experience with intrauterine intralesional injection of OK-432 in the treatment of neck lymphangiomas. Two cases of large multicystic neck lymphangiomas that were closely situated to the fetal airway were treated by single intralesional injection of OK-432. We noticed a progressive decrease in tumor volume throughout gestation. We did not experience any complications and there were no respiratory or feeding problems in the neonates. The esthetical appearance was satisfactory and both children were normal at the age of 2 years and 6 months, respectively. This report suggests that prenatal intralesional injection of OK-432 might be a safe and effective treatment in selected cases with large fetal neck lymphangiomas.

[The effect of anogenital warts on life quality of affected patients].

INTRODUCTION: Anogenital warts represent a clinical manifestation of the infection of the lower female genital tract, human papilloma viruses types 6 and 11. They belong to the group of sexually transmitted diseases and then may be localized either on the female or male genitalia. The aim of the study was to show the effect of anogenital warts on life quality of the affected patients. MATERIAL AND METHODS: The study was conducted on 200 female patients using the standardized questionnaire filled in by patients under the researcher's supervision immediately before laser wart removal. Each question out of 15 could be answered by one of the suggested answers: always, almost always, sometimes, rarely and never. The answer "always" was worth one point, "almost always" two points, "sometimes" three points, "rarely" four points and never "five" points. Life quality was categorized as bad, tolerable, good, very good and excellent. The lower number of points in the questionnaire indicated the worse life quality and the higher number of points demonstrated a better life quality. RESULTS: The study results showed that the highest number of subjects was in the third and fourth decade of life. The presence of anogenital warts had an effect on life quality in most patients. 5% of subjects assessed their life quality as bad, 16% as tolerable, 45% as good and 23% as very good. Only in 11% of patients the presence of anogenital warts did not have any effect on life quality (chi2 = 121.680, p < 0.001). CONCLUSION: The presence of anogenital warts has a significant effect on life quality of affected patients, indicating the significance of their early detection and treatment.

Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience.

INTRODUCTION: Metoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. AIM: Our aim is to describe our technique and highlight its advantages. METHODS: Between September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed. MAIN OUTCOME MEASURES: Patients' personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data. RESULTS: The median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients. CONCLUSIONS: Metoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

Uterine compression suture technique in the management of severe postpartum haemorrhage as an alternative to hysterectomy.

INTRODUCTION: One of the most dramatic conditions in obstetrics is definitely bleeding from the uterus which fails to compress. This condition is known as postpartum atony. When such a condition is diagnosed, the obstetrician has a choice of several conservative methods to stimulate the uterus to contract and several surgical methods to stop the bleeding. The most extreme measure used to save the patient's life and stop the bleeding is hysterectomy. This surgery is characterized by high morbidity, primarily by the loss of woman's fertility. In order to avoid hysterectomy, several authors have introduced the compressive uterine suture technique into gynaecological practice. OBJECTIVE: The aim of the paper is to demonstrate the technique of applying compressive uterine suture after delivery to stop excessive bleeding, and to present results obtained by this technique. METHODS: The paper explains the technique of applying compressive suture to the atonic uterus in cases when all other procedures to stop excessive bleeding after delivery fail. Since uterine atony is the main reason for excessive and uncontrollable bleeding after childbirth, the need to perform such surgery is rather common. Authors demonstrate the technique of applying four compressive sutures which prevent uterus dilation and thus stop the bleeding. RESULTS: Compressive suture technique was used by the authors eight times, seven of which during caesarean section and one after spontaneous delivery. All patients had normal postpartum period and normal involution of the uterus. CONCLUSION: Although this surgery requires a skillful and experienced obstetrician, the authors find it rather easy to perform and it is suggested to be applied in all cases of uterine atony when excessive bleeding cannot be stopped by other any other method except hysterectomy. This surgical procedure saves the uterus and facilitates quick and easy patient's recovery.

Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias.

OBJECTIVES: Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias. METHODS: Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin. RESULTS: The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment. CONCLUSIONS: Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.

Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery.

OBJECTIVES: To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse. METHODS: From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity. RESULTS: The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision. CONCLUSIONS: Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.

[Myomectomy via the vagina]. / Miomektomija kroz vaginu.

In recent years, the development of new surgical techniques in uterus myoma treatment have reduced operative trauma significantly. Our objective was to present operative technique--vaginal myomectomy, making a prospective clinical study where we have evaluated the operative and postoperative period after intentive diagnosis. The result of our study shows the feasibility of myomectomy by entering the peritoneum through the posterior vaginal fornix, using traditional and cheap surgical instruments and thus avoiding the trauma of laparatomy, minimal operative blood loss, reduced operating time and postoperative recovery. In our opinion, vaginal myomectomy could be useful for the treatment of selected cases with fundal or posterior wall uterine myomas.

A highly potent artificial transcription factor.

The use of synthetic chemical moieties to design fully functional analogues of transcription factors will give rise to novel molecular tools for targeted gene regulation. Here we demonstrate that a synthetic molecule based on a nonpeptidic DNA-binding domain can be engineered to function as a highly potent transcription factor in vitro and in an intracellular context. The structure of this artificial transcription factor (ATF) consists of three parts: (i) triple-helix-forming oligonucleotide as a DNA-binding domain; (ii) composite linker moiety; and (iii) short synthetic peptide. The direct comparison of ATFs with natural transcription factors in in vitro assays reveals the ability of ATFs to initiate RNA transcription at the correct initiation site. In addition, the transcriptional activation potency of ATFs in vitro matches or exceeds the potency of GAL4-VP16, one of the strongest natural transcriptional activators. This remarkable biological activity is explained as a function of ATF's chemical structure. We also demonstrate for the first time that ATFs possess substantial ability to activate transcription in tissue culture cells, thus opening a prospect for practical applications in basic and applied research. The specific molecular design employed in the synthesis of ATFs may lead to the development of novel gene-targeting pharmaceuticals for treatment of fatal and chronic diseases.