Anterior enterocele after cystectomy: case report and review of the literature.

PURPOSE: Anterior enterocele is a rare but potentially serious complication after cystectomy with heterogeneous treatment options. METHODS: Here we report on the management of a 71-year-old patient with recurrence of anterior enterocele after cystectomy and provide a systematic review of the literature using the PubMed/MEDLINE database. RESULTS: The 71-year-old patient with recurrence of anterior enterocele after cystectomy was successfully treated with colpocleisis and anterior colporrhaphy at the Department of Gynecology and Gynecological Oncology, University Hospital Bonn. The use of a synthetic mesh was not needed. At 16-month follow-up postoperatively, the patient was asymptomatic and had no signs of recurrence. n = 14 publications including n = 39 patients were identified for the systematic review including case reports and reviews. The median duration of developing an anterior enterocele after cystectomy was 9 months (range 3 months to 8 years). Patients had a median age of 71 years (range 44-84). In all cases, a surgical approach was described using a wide variety of surgical procedures. In total, 36% of all patients developed a recurrence with an average time period of 7 months after primary surgery. A rare complication represents a vaginal evisceration with the need of urgent surgery. Furthermore, the occurrence of a fistula is a possible long-term complication. CONCLUSION: Anterior enterocele after cystectomy is a rare complication requiring an individual and interdisciplinary treatment.

Optimized complete cytoreduction in ovarian cancer through intraoperative real-time tumor visualization by 5-ALA - a case report.

Introduction: Complete macroscopic cytoreduction represents the most important prognostic parameter for overall survival in ovarian cancer. This dogma remains tenacious despite significant improvements in adjuvant systemic treatment. Hence, optimization of surgical therapy is an overarching goal to improve patients' outcomes. In this context, intraoperative tumor-specific imaging might facilitate optimized cytoreduction. In neurosurgery, intraoperative 5-aminolevulinic acid (5-ALA) guided imaging is applied in clinical routine to assess surgical resection margins. Here, we report the case of a patient with ovarian cancer in whom intraoperative 5-ALA tumor visualization led to optimized complete cytoreduction. Objective: Intraoperative administration of 5-ALA led to improved complete cytoreduction by identification and resection of additional ovarian cancer tumor manifestations. Case: The 39-year-old patient, Jehovah`s witness, presented to our department with a left sided ovarian mass, suspicious of ovarian cancer, based on clinical examination, sonographic suspicious features and a CA12-5 elevation. The patient's medical history and family history was unremarkable. Preoperative CT imaging of the thorax and abdomen showed no pathology besides the adnexal mass. Surgery was performed by a midline laparotomy with hysterectomy, bilateral adnexectomy, pelvic peritonectomy, omentectomy, ureterolysis, diaphragm stripping, adhesiolysis and the collection of peritoneal and rectal samples. Intraoperative 5-ALA imaging using a dedicated excitation and detection loupe system (Reveal, DVI) led to tumor detection at the diaphragm, the omentum and the rectum that was not detectable by palpation and visualization using white light. The pathology results revealed that the 5-ALA positive samples (diaphragm, rectum and omentum) obtained by intraoperative 5-ALA were positive for ovarian cancer. Conclusion: Intraoperative administration of 5-ALA represents a promising approach to improve complete cytoreduction in ovarian cancer surgery thereby improving clinical outcomes. Hence, further research and clinical trials are required to investigate the potential of intraoperative 5-ALA imaging in ovarian cancer debulking surgery and its impact on long-term clinical outcomes.

Risk Factors for Severe Pain and Impairment of Daily Life Activities after Cesarean Section-A Prospective Multi-Center Study of 11,932 Patients.

Cesarean section (CS) is the most widely performed and one of the most painful surgeries. This study investigated postoperative pain after CS using patient-related outcomes (PROs) to identify risk factors for severe pain. The secondary outcome was to evaluate the influence of surgery indication (primary CS (PCS) vs. urgent CS (UCS)). This multi-center, prospective cohort study included data submitted to the pain registry "quality improvement in postoperative pain treatment" (QUIPS) between 2010 and 2020. In total, 11,932 patients were evaluated. Median of maximal pain was 7.0 (numeric rating scale (NRS) 0 to 10); 53.9% suffered from severe pain (NRS ≥ 7), this being related to impairment of mood, ambulation, deep breathing and sleep, as well as more vertigo, nausea and tiredness (p < 0.001). Distraction, relaxation, mobilization, having conversations, patient-controlled analgesia (PCA) and pain monitoring were shown to be protective for severe pain (p < 0.001). Maximal pain in PCS and UCS was similar, but UCS obtained more analgesics (p < 0.001), and experienced more impairment of ambulation (p < 0.001) and deep breathing (p < 0.05). Severe pain has a major effect on daily-life activities and recovery after CS, and depends on modifiable factors. More effort is needed to improve the quality of care after CS.

Development of an ectopic huLiver model for Plasmodium liver stage infection.

Early Plasmodium falciparum and P. vivax infection requires parasite replication within host hepatocytes, referred to as liver stage (LS). However, limited understanding of infection dynamics in human LS exists due to species-specificity challenges. Reported here is a reproducible, easy-to-manipulate, and moderate-cost in vivo model to study human Plasmodium LS in mice; the ectopic huLiver model. Ectopic huLiver tumors were generated through subcutaneous injection of the HC-04 cell line and shown to be infectible by both freshly dissected sporozoites and through the bite of infected mosquitoes. Evidence for complete LS development was supported by the transition to blood-stage infection in mice engrafted with human erythrocytes. Additionally, this model was successfully evaluated for its utility in testing antimalarial therapeutics, as supported by primaquine acting as a causal prophylactic against P. falciparum. Presented here is a new platform for the study of human Plasmodium infection with the potential to aid in drug discovery.

Maternal and neonatal outcome of births planned in alongside midwifery units: a cohort study from a tertiary center in Germany.

BACKGROUND: For healthy women entering birth after uneventful pregnancy, midwife-led models of care have the potential to reduce interventions and increase the vaginal birth rate. In Germany, 98.4% of women are giving birth in consultant-led obstetric units. Alongside midwifery units (AMU) have been established in 2003. We compared the outcome of women registered for planned birth in the AMU at our hospital with a matched group of low-risk women who gave birth in standard obstetric care during the same period of time. METHODS: We used a retrospective cohort study design. The study group consisted of all women admitted to labor ward who had registered for birth in AMU from 2010 to 2017. For the control group, low-risk women were selected; additionally, matching was performed for parity. Mode of birth was chosen as primary outcome parameter for the mother. For the neonate, a composite primary outcome (5-min Apgar < 7 or umbilical cord arterial pH < 7.10 or transfer to specialist neonatal care) was defined. Secondary outcomes included epidural anesthesia, duration of the second stage of labor, episiotomy, obstetric injury, and postpartum hemorrhage. Non-inferiority was assessed, and multiple logistic regression analysis was performed. RESULTS: Six hundred twelve women were admitted for labor in AMU, the control group consisted of 612 women giving birth in standard obstetric care. Women in the study group were on average older and had a higher body mass index (BMI); birthweight was on average 95 g higher. Non-inferiority could be established for the primary outcome parameters. Epidural anesthesia and episiotomy rates were lower, and the mean duration of the second stage of labor was shorter in the study group; second-degree perineal tears were less common, higher-order obstetric lacerations occurred more frequently. Overall, 50.3% of women were transferred to standard obstetric care. Regression analysis revealed effects of parity, age and birthweight on the chance of transfer. CONCLUSION: Compared to births in our consultant-led obstetric unit, the outcome of births planned in the AMU was not inferior, and intervention rates were lower. Our results support the integration of AMU as a complementary model of care for low-risk women.

The middle ear pressure does not change after adenotonsillectomy in children younger than 10 years old.

OBJECTIVE. In children aged less than 10 years, to assess whether adenotonsillectomy has some permanent or transitory effect on middle ear pressure. MATERIAL AND METHODS. 20 children aged 4 to 9 years old (13 girls and 7 boys) participated in the study. The day before surgery and on days 1, 7, 14 and 21 after adenotonsillectomy both tympanometry and pure tone audiometry were performed. During surgery, medication consisted in dexamethasone, atropine, propofol and sevoflurane. RESULTS. Before surgery, the middle ear pressure was within the range of 0 ± 99 daPa. On day 1 of the followup study, the average right and left middle ear pressure decreased less than -99 daPa in 6 patients aged 4 to 9 years old (2 girls and 4 boys), with a body mass index from 11.9 to 16.6. At day 7 of follow-up, the middle ear pressure increased and none of the patients showed a pressure less than -99 daPa. Before surgery and during the 21 days of follow-up, hearing thresholds were always ≤ 20 dB nHL. No significant difference was observed between children with or without an average middle ear pressure lower than -99 daPa on their age, weight, height, body mass index or duration of the surgery. CONCLUSIONS. After adenotonsillectomy, children aged 4 to 9 years old who received dexamethasone, atropine and sevoflurane might develop negative middle ear pressure with no hearing loss, which may resolve in 1 week. After adenotonsillectomy, in patients with otalgia or risk factors for middle ear disease, closer evaluation of middle ear pressure may be advisable.

Repeatability of static posturography on the follow-up of vestibular rehabilitation.

BACKGROUND AND AIMS: We undertook this study to estimate the limits of agreement of repeated measures of static posturography on healthy adults and to assess the use of those limits on the interpretation of variations observed during vestibular rehabilitation of patients with chronic, peripheral vestibular disease. METHODS: Twenty healthy adults and 30 vestibular patients accepted to participate. At baseline and at weeks 4, 6 and 8 of follow-up, posturography was performed with the eyes open or closed, while adding or not a layer of foam rubber to the base of support. The Dizziness Handicap Inventory was administered to patients prior to rehabilitation and at week 8. RESULTS: At baseline, a difference between groups was observed on the sway area (p < 0.05). Healthy subjects showed no statistical difference among the four recordings (repeatability of measurements from 85-100%). Vestibular patients showed differences among the four recordings on the area and the length/average speed of sway (p <0.05); individual differences from baseline exceeding the limits of agreement were observed on the sway area. A decrease on the Dizziness Handicap Inventory (≥18 points) was observed on 19 patients, from whom 12 (63, 95% CI 53-73%) showed a change on the sway area (eyes closed) that was larger than the limits of agreement. CONCLUSIONS: In healthy subjects, intra-subject repeated recordings of the area and the length/average speed of sway may be reliable at intervals of 4, 6 and 8 weeks. The sway area (without vision) may be a useful sway component, among others, to follow-up vestibular patients with chronic, peripheral disease during rehabilitation.

[Perinatal encephalopathy sequelae identified by a neurobehavioral scale in one year old infants]. / Secuelas de encefalopatía perinatal identificadas con una escala de desarrollo neuroconductual.

OBJECTIVE: to identify neurodevelopmental sequelae in one year old infants with perinatal encephalopathy utilizing the neurobehavioral scale named Vanedela. METHODS: a cohort of 75 newborns with perinatal encephalopathy was assessed with a neurobehavioral follow-up scale at age of 1, 4, 8 and 12 months. A distinction was made between functional, structural and combined encephalopathy. Two groups of neurodevelopmental outcome at one year were identified: with or without sequelae. Nonparametric statistics was used. RESULTS: infants with functional encephalopathy had the best scores, followed by those with structural encephalopathy, while infants with a combined encephalopathy had the lowest scores. At one year of age, the group with neurobehavioral sequelae exhibited the lowest scores and retarded growth. At the same age, the group with functional encephalopathy exhibited no neurobehavioral sequelae, and reached better scores and growth. CONCLUSIONS: the neurobehavioral follow-up scale is able to identify the neurodevelopmental sequelae at the age of one year in infants with perinatal encephalopathy. The application of Vanedela in the clinical field requires of little time, its results are trustworthy and very useful for the neurobehavioral follow-up assessment.

Influence of obesity and gender on the postural stability during upright stance.

OBJECTIVE: To assess the influence of BMI group (lean/overweight/obese) and gender on the postural sway of adults and adolescents during quiet upright stance. METHODS: 90 women and 90 men, aged 12 to 67 years old, accepted to participate. The center of pressure during quiet upright stance was recorded using a force platform, during 4 conditions (eyes open/closed on hard/soft surface). Statistical analysis was performed using multivariate analysis of covariance. RESULTS: During recordings on hard surface, closing the eyes produced a larger increase of sway on obese subjects than on lean and overweight subjects, with a larger increase on the length and the area of sway. Although gender differences were found during the four sensory conditions, no interaction was observed between the BMI group and the gender. These results were not related to the age of the subjects. CONCLUSION: Compared to non-obese subjects, the postural stability of obese subjects may be more vulnerable when vision is not available, with no influence of the gender.

[Peroxisomal D-bifunctional enzyme deficiency. A case report]. / Deficencia enzimática D-bifuncional peroxlsomal. Caso clínico.

Newborn was referred with diagnosis of neonatal epilepsy. Medical team could suspect and confirm D-bifunctional peroxisomal enzymatic deficiency diagnosis. It was made by family antecedents, severe neonatal hypotonia, uncontrolled neonatal seizures, craniofacial dysmorphic features, psychomotor retardation, neuronal migration defect and a positive peroxisomal panel. The full study in skin fibroblasts involved enzyme analysis, complementation studies and DNA analysis. The accumulation of very long chain fatty acids, partial deficiency in phytanic acid oxidation, and abnormal morphology of peroxisomes was consistent with a defect in peroxisomal fatty acid oxidation, involving D-bifunctional protein. It is very important to make a diagnosis of this innate error of metabolism in order to give preconceptional genetic counseling, to identify recurrence risk and to perform mutation analysis for the D-bifunctional protein gene, and to offer the prenatal diagnosis.

The effect of vestibular rehabilitation supplemented by training of the breathing rhythm or proprioception exercises, in patients with chronic peripheral vestibular disease.

OBJECTIVE: To assess the effect of performing vestibular rehabilitation using the Cawthorne & Cooksey exercises supplemented by training of the breathing rhythm or proprioception exercises on self-reported disability and postural control, in patients with chronic, peripheral, vestibular disease. METHODS: Fifty one patients with peripheral vestibular disease and abnormal caloric test participated in the study (mean age 43 +/- S.D. 9 years). They were assigned to one of 3 treatment groups: I. Cawthorne &} Cooksey exercises with training of the breathing rhythm (n=17); II. Cawthorne & Cooksey exercises with proprioception exercises (n=17) and III. Cawthorne & Cooksey exercises with no additional intervention (n=17). The Dizziness Handicap Inventory and static posturography were evaluated prior to treatment and at week 8 of follow-up. RESULTS: Prior to treatment, composite scores on the Dizziness Handicap Inventory and static posturography were similar in the 3 groups. After treatment, a decrease of the composite score of at least 18 points was observed more frequently in patients of the respiration group (94%), compared to the proprioception group (53%) and the Cawthorne & Cooksey group (70%) (p=0.03); while the proprioception group showed a significant decrease of oscillation during all sensory conditions of static posturography (p< 0.05). CONCLUSION: The results suggest that regulation of the breathing pattern may have an influence on disability related to chronic vestibular disease, while proprioception exercises may improve postural control. However, further studies are needed to evaluate if training of the breathing rhythm could be an additional tool for vestibular rehabilitation.

[Disability due to auditory and vestibular dysfunction in a specialized care center]. / Discapacidad por enfermedad auditiva y vestibular en un centro de atención especializada.

OBJECTIVE: To assess the frequency and characteristics of the disability associated with hearing loss and vestibular disease in a Specialized Medical Center of the Mexican Social Security Institute. METHODS: 530 patients agreed to participate. They were assessed due to hearing loss (n = 252) and vestibular disease (n = 278), 54% and 50% of them worked. After a clinical evaluation and administration of a symptom questionnaire, they were asked about the frequency and days ofdisability to perform daily life activities related to their audiological or vestibular disease and how often they visited the physician during the last year because of their symptoms. RESULTS: Hearing loss patients visited the physician 1-6 times/ year and 15.8% reported disability. Vestibular patients visited the physician 1-8 times/ year and reported disability more frequently (60.8%) (p < 0.01). Among those who worked, 5% of patients with hearing loss and 51% of patients with vestibular disease stopped working during 1-15 cumulative days for the first group and 1-365 cumulative days for the second group. Spearmnan's correlation coefficient between the evolution of the disease and disability days was -0.14 (p < 0.01) for hearing loss patients and -0.27 (p < 0.01 ) for vestibular disease. CONCLUSION: Vestibular disease is a cause of disability. which can have financial impact on both the patient and the health care system.

Discapacidad por enfermedad auditiva y vestibular en un centro de atención especializada / Disability due to auditory and vestibular dysfunction in a specialized care center

Objetivo: identificar la limitación que en su vida diaria padecen los pacientes evaluados por hipoacusia o enfermedad vestibular en un Centro de Atención Especializada del IMSS. Método: participaron 530 pacientes evaluados por primera vez con hipoacusia (n=252) o enfermedad vestibular (n=278), de los cuales eran económicamente activos 54 y 50% respectivamente. Después de la evaluación especializada y de la administración un cuestionario de síntomas co cleovestibulares, se identificó la frecuencia y número de días de discapacidad relacionados con la hipoacusia o enfermedad vestibular y la frecuencia de consultas médicas durante el último año. Resultados: los pacientes con hipoacusia solicitaron consulta médica 1-6 veces/año y 15.8% informaron discapacidad. Mientras que aquéllos con enfermedad vestibular solicitaron 1-8 consultas e informaron discapacidad con más frecuencia (60.8%) (p < 0.01); de los pacientes económicamente activos 5% con hipoacusia y 51% con enfermedad vestibular había tenido discapacidad laboral, de 115 días acumulados para el primer grupo y de 1 365 días para el segundo grupo. La correlación entre el tiempo de evolución de la enfermedad y los días de discapacidad por hipoacusia fue de r de Spearman -0.14 (p < 0.01) y -0.27 (p < 0.01) por enfermedad vestibular. Conclusión. La enfermedad vestibular produce discapacidad, que puede ser prolongada, con implicaciones económicas tanto para el paciente como para la institución que le otorga la atención médica.

Objective: To assess the frequency and characteristics of the disability associated with hearing loss and vestibular disease in a Specialized Medical Center of the Mexican Social Security Institute. Methods: 530 patients agreed to participate. They were assessed due to hearing loss (n=252) and vestibular disease (n=278), 54% and 50% of them worked. After a clinical evaluation and administration of a symptom questionnaire, they were asked about the frequency and days of disability to perform daily life activities related to their audiological or vestibular disease and how often they visited the physician during the last year because of their symptoms. Results: Hearing loss patients visited the physician 1-6 times/ year and 15.8% reported disability. Vestibular patients visited the physician 1-8 times/ year and reported disability more frequently (60.8%) (p < 0.01). Among those who worked, 5% of patients with hearing loss and 51% of patients with vestibular disease stopped working during 115 cumulative days for the first group and 1 365 cumulative days for the second group. Spearman's correlation coefficient between the evolution of the disease and disability days was -0.14 (p < 0.01) for hearing loss patients and -0.27 (p < 0.01 ) for vestibular disease. Conclusion. Vestibular disease is a cause of disability, which can have financial impact on both the patient and the health care system.

The LEI/L-DNase II pathway is activated in light-induced retinal degeneration in rats.

Retinal death induced by light seems to be a caspase-independent process. In this work we investigate the LEI/L-DNase II pathway, a caspase-independent pathway, in light-induced retinal degeneration in Fischer rats. Measurement of DNase activity in total retinal extracts of light exposed Fischer rats was performed by analysing a plasmid degradation on an agarose gel. The same method was used to measure the in vitro activity of recombinant LEI (reticulocyte lysate) after incubation with calpains. L-DNase II activity is observed in retinal extracts of light exposed Fischer rats and increases with time illumination. In this apoptotic death, the activation of calpains has been shown. Here we show that L-DNase II activation is not catalized by calpains. The present study indicates that the LEI/L-DNase II may be a possible pathway activated during photoreceptor apoptosis in light-induced retinal degeneration but that this pathway is not directly activated by calpains.