Internal and external adenomyosis phenotypes: ultrasound features and association with clinical outcomes.

STUDY QUESTION: What are the sonographic and clinical findings in women diagnosed with external and internal adenomyosis by ultrasound? SUMMARY ANSWER: Patients with external and internal adenomyosis phenotypes, diagnosed by ultrasound, present differences in sonographic features of the disease and demographic characteristics including age, parity, and association with deep endometriosis (DE) and leiomyomas. WHAT IS KNOWN ALREADY: Two different phenotypes of adenomyosis have been described based on the anatomical location of adenomyotic lesions in the myometrium, suggesting that adenomyosis affecting the inner myometrium and that affecting the external myometrial layer may have distinct origins. STUDY DESIGN, SIZE, DURATION: A cross-sectional study including 505 patients with a sonographic diagnosis of adenomyosis was performed between January 2021 and December 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: Women sonographically diagnosed with adenomyosis in a tertiary referral hospital that serves as a national reference center for endometriosis were included over a 2-year period. Patients were divided into two groups (internal and external adenomyosis) according to the myometrial layer affected by adenomyosis. We compared sonographic and clinical outcomes including a multivariate analysis between the two groups. MAIN RESULTS AND THE ROLE OF CHANCE: According to ultrasound findings, 353 (69.9%) patients presented with internal adenomyosis, while 152 (30.1%) presented with external adenomyosis. Women with internal adenomyosis were significantly older and less frequently nulliparous compared to those with external adenomyosis. Sonographically, internal adenomyosis appeared diffusely, it had a greater number of adenomyosis features, it presented a globular morphology of the uterus more frequently, and it coexisted with leiomyomas more frequently, compared to external adenomyosis. Conversely, the presence of translesional vascularity and associated DE were more common among the external adenomyosis group. No significant differences were found between internal and external adenomyosis groups regarding pain, heavy menstrual bleeding, spotting, or infertility. In the multivariate analysis, nulliparity, the presence of leiomyomas, and the presence of DE were independently associated with adenomyosis phenotypes (the presence of DE and nulliparity increased the risk of external adenomyosis, whereas the presence of leiomyomas was a risk factor for internal adenomyosis). Considering the impact of hormonal treatment, we found that the number of ultrasound adenomyosis criteria was significantly greater in patients without hormonal treatment. Non-treated patients more commonly presented dysmenorrhea or bleeding-associated pain and heavy menstrual bleeding than women on hormonal treatment, although there were no significant differences according to adenomyosis phenotypes. LIMITATIONS, REASONS FOR CAUTION: As the population was selected from the Endometriosis Unit of a tertiary center, there may be patient selection bias, given the high prevalence of individuals with associated endometriosis, previous endometriosis-related surgery, and/or receiving hormonal treatment. WIDER IMPLICATIONS OF THE FINDINGS: Transvaginal ultrasound is the most available and cost-effective tool for the diagnosis of adenomyosis. Adenomyosis phenotypes based on ultrasound findings may be key in achieving an accurate diagnosis and in decision-making regarding the most adequate therapeutic strategy for the management of patients with adenomyosis. Determination of the sonographic features associated with symptoms could help in the evaluation of treatment response. STUDY FUNDING/COMPETING INTEREST(S): No funding was obtained for this study and there are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

El tratamiento hormonal es imperativo para todas las pacientes: lo antes posible y siempre / Hormone treatment is imperative for all patients: As soon as possible and always

La endometriosis se considera una enfermedad inflamatoria crónica sistémica benigna y hormonodependiente que afecta aproximadamente a un 10% de las mujeres en edad fértil. Parece que cambios innatos o adquiridos de la capacidad del endometrio para implantar, invadir y crecer en un ambiente inflamatorio con dependencia estrogénica, así como la resistencia a la progesterona son características fundamentales para la aparición y desarrollo de la endometriosis. No existe, por el momento, ningún tratamiento óptimo que consiga alcanzar los cuatro objetivos básicos del tratamiento de la endometriosis: suprimir los síntomas, restaurar la fertilidad, eliminar la endometriosis visible, y evitar la progresión de la enfermedad. Puesto que la enfermedad se considera crónica, el tratamiento médico administrado, hasta la llegada de la menopausia o de una gestación, debe ser de larga duración, efectivo y seguro. Así pues, sus objetivos reales serán la reducción o eliminación de los síntomas y/o mejoría de la fertilidad. Dadas las limitaciones y riesgos de las cirugías, el tratamiento de primera elección en la actualidad es el hormonal. Este debe individualizarse en función de la edad, paridad, deseo genésico, síntomas asociados, antecedentes patológicos y preferencias de la paciente. De forma global, existen dos tipos de tratamientos de primera elección: los estroprogestágenos en regímenes extendidos o continuos y algunos progestágenos en diferentes vías de administración (dienogest, acetato de noretisterona o desogestrel por vía oral, así como el dispositivo intrauterino de levonorgestrel de alta dosis). Los diferentes tratamientos y sus pros y contras se exponen en el artículo.(AU)

Endometriosis is nowadays considered an inflammatory chronic benign disease that responds to hormone manipulation and affects up to 10% of women in fertile age. It seems that innate or acquired changes in the endometrium ability to implant, invade and grow in an inflammatory milieu with estrogenic dependence and progesterone resistance are the responsible for new endometriosis implants and contribute to perpetuate the illness. There is, at the moment, no optimal known treatment that achieves the four basic objectives for the treatment of endometriosis: treat the symptoms, improve fertility, eliminate endometrial implants, and avoid illness progression. As is now considered a chronic condition, the prescribed medical treatment, until the patient arrives to the physiological menopause status or gets pregnant, must be considered in the long term, and must be effective and safe. Therefore, the realistic objectives of the treatment are the reduction or abolishment of symptoms and/or improve fertility. As a consequence of the limitations and risks of endometriosis surgeries, the first-line treatment is hormonal. This must be individualized according to age, parity, pregnancy desire, associated symptoms, other illnesses and patients preferences. Globally, there are two main types of first-line hormonal treatments: estroprogestins in extended or continuous regimens and some progestins in different routes of administration (dienogest, norethisterone acetate or desogestrel orally, and levonorgestrel high-dose intrauterine device). The different hormonal treatments and their pros and cons are explained in the manuscript.(AU)

Seguridad en procedimientos dermatológicos: sección de grandes vasos sanguíneos y estructuras nerviosas / Safety in Dermatologic Procedures: Accidental Injury to Major Blood Vessels and Nerve Structures

En el presente artículo de la serie «Seguridad en procedimientos dermatológicos» se aborda la sección quirúrgica accidental de grandes vasos sanguíneos y estructuras nerviosas. Se aborda, en primer lugar, la localización anatómica y recorrido de las distintas estructuras vasculares y nerviosas de más riesgo. A continuación, se explican las consecuencias de dicha lesión. Por último, se emiten algunas recomendaciones para evitar el daño accidental de las estructuras en dichas áreas de riesgo y se plantean algunas maniobras terapéuticas de reparación ante un eventual daño (AU)

This article in the series «Safety in Dermatologic Procedures» deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised (AU)

[Translated article] Safety in Dermatologic Procedures: Accidental Injury to Major Blood Vessels and Nerve Structures / Seguridad en procedimientos dermatológicos: sección de grandes vasos sanguíneos y estructuras nerviosas

This article in the series «Safety in Dermatologic Procedures» deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised (AU)

En el presente artículo de la serie «Seguridad en procedimientos dermatológicos» se aborda la sección quirúrgica accidental de grandes vasos sanguíneos y estructuras nerviosas. Se aborda, en primer lugar, la localización anatómica y recorrido de las distintas estructuras vasculares y nerviosas de más riesgo. A continuación, se explican las consecuencias de dicha lesión. Por último, se emiten algunas recomendaciones para evitar el daño accidental de las estructuras en dichas áreas de riesgo y se plantean algunas maniobras terapéuticas de reparación ante un eventual daño (AU)

Significant differences in efficiency between two commonly used ionophore solutions for assisted oocyte activation (AOA): a prospective comparison of ionomycin and A23187.

PURPOSE: Despite the success of ICSI in treating severe male factor infertile patients, total fertilization failure (FF) still occurs in around 1-3% of ICSI cycles. To overcome FF, the use of calcium ionophores has been proposed to induce oocyte activation and restore fertilization rates. However, assisted oocyte activation (AOA) protocols and ionophores vary between laboratories, and the morphokinetic development underlying AOA remains understudied. METHODS: A prospective single-center cohort study involving 81 in vitro matured metaphase-II oocytes from 66 oocyte donation cycles artificially activated by A23187 (GM508 CultActive, Gynemed) (n=42) or ionomycin (n=39). Parthenogenesis was induced, and morphokinetic parameters (tPNa, tPNf, t2-t8, tSB, and tB) were compared between the 2 study groups and a control group comprising 39 2PN-zygotes from standard ICSI cycles. RESULTS: Ionomycin treatment resulted in higher activation rates compared to A23187 (38.5% vs 23.8%, p=0.15). Importantly, none of the A23187-activated parthenotes formed blastocysts. When evaluating the morphokinetic dynamics between the two ionophores, we found that tPNa and tPNf were significantly delayed in the group treated by A23187 (11.84 vs 5.31, p=0.002 and 50.15 vs 29.69, p=0.005, respectively). t2 was significantly delayed in A23187-activated parthenotes when compared to the double heterologous control embryo group. In contrast, the morphokinetic development of ionomycin-activated parthenotes was comparable to control embryos (p>0.05). CONCLUSION: Our results suggest that A23187 leads to lower oocyte activation rates and profoundly affects morphokinetic timings and preimplantation development in parthenotes. Despite our limited sample size and low parthenote competence, standardization and further optimization of AOA protocols may allow wider use and improved outcomes for FF cycles.

Safety in Dermatologic Procedures: Accidental Injury to Major Blood Vessels and Nerve Structures. / Seguridad en procedimientos dermatológicos: sección de grandes vasos sanguíneos y estructuras nerviosas.

This article in the series «Safety in Dermatologic Procedures¼ deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised.

Clinical and sonographic impact of oral contraception in patients with deep endometriosis and adenomyosis at 2 years of follow-up.

Nowadays, combined oral contraceptives (COCs) are successfully employed for the treatment of endometriosis (END) and adenomyosis (AD) in a large proportion of patients. However, literature focusing on the clinical and sonographic response to treatment in the long-term follow-up of patients with deep endometriosis (DE) and AD is scarce. The aim of this study was to evaluate the changes in the symptoms and the sonographic exams at 12 and 24 months of follow-up in patients who had received a flexible extended COC regimen containing 2 mg of dienogest/30 µg ethinyl estradiol. This prospective, longitudinal, observational study included women diagnosed with DE and AD presenting no surgical indication and were candidates to treatment with COCs. The presence and severity of dysmenorrhea, non-menstrual pelvic pain, deep dyspareunia, dyschezia and dysuria were evaluated using the Numerical Rating Scale (NRS) at baseline, and at 12 and 24 months of treatment. Transvaginal ultrasound was also performed at these check points searching for criteria of AD and reporting the size of the DE nodules and ovarian endometriomas (OE). Sixty-four patients were included. A significant decrease in the number of patients with severe dysmenorrhea and non-menstrual pelvic pain was reported during follow-up. The mean NRS score for dysmenorrhea, non-menstrual pelvic pain, deep dyspareunia, dyschezia and dysuria was also significantly lower at follow-up. There was a significant reduction in the sonographic number and type of AD criteria during follow-up after treatment. Similarly, a significant decrease in the size of OE and uterosacral ligament involvement in DE was observed at the 12-month follow-up, with a further, albeit not statistically significant, decrease in the 12- to 24-month follow-up. Additionally, torus and rectosigmoid DE decreased in size, although the reduction was not statistically significant at any study point. This prospective study suggests a clinical and sonographic improvement after a flexible extended COC regimen in DE and AD patients, which was significant at 12 months of follow-up. The improvement was more evident in AD and OEs compared with DE. Further research with a longer follow-up, larger sample size and comparison with other treatments is needed.

Incidental Primary Intrathoracic Goiter: Dual-Isotope Scintigraphy and Early-MIBI SPECT/CT.

Primary intrathoracic goiter is an uncommon congenital entity resulting from over decent ectopic thyroid tissue. As compared with secondary intrathoracic goiter, primary entities are discrete from orthotopic thyroid tissue and may lead to potentially serious complications such as malignancy and shortness of breath. Intrathoracic goiters have been described as showing mild or absent uptake of 99m Tc-pertechnetate on planar scintigraphy. We present an incidental primary intrathoracic goiter found in a patient undergoing evaluation with multimodal scintigraphy and early 99m Tc-sestamibi single-photon emission computed tomography/computed tomography (SPECT/CT) for localization of parathyroid adenomas. The mass was inconspicuous on TcO 4- scintigraphy but methoxyisobutylisonitrile-avid on early planar and SPECT/CT.

Autophagy is Involved in Cardiac Remodeling in Response to Environmental Temperature Change.

Objectives: To study the reversibility of cold-induced cardiac hypertrophy and the role of autophagy in this process. Background: Chronic exposure to cold is known to cause cardiac hypertrophy independent of blood pressure elevation. The reversibility of this process and the molecular mechanisms involved are unknown. Methods: Studies were performed in two-month-old mice exposed to cold (4°C) for 24 h or 10 days. After exposure, the animals were returned to room temperature (21°C) for 24 h or 1 week. Results: We found that chronic cold exposure significantly increased the heart weight/tibia length (HW/TL) ratio, the mean area of cardiomyocytes, and the expression of hypertrophy markers, but significantly decreased the expression of genes involved in fatty acid oxidation. Echocardiographic measurements confirmed hypertrophy development after chronic cold exposure. One week of deacclimation for cold-exposed mice fully reverted the morphological, functional, and gene expression indicators of cardiac hypertrophy. Experiments involving injection of leupeptin at 1 h before sacrifice (to block autophagic flux) indicated that cardiac autophagy was repressed under cold exposure and re-activated during the first 24 h after mice were returned to room temperature. Pharmacological blockage of autophagy for 1 week using chloroquine in mice subjected to deacclimation from cold significantly inhibited the reversion of cardiac hypertrophy. Conclusion: Our data indicate that mice exposed to cold develop a marked cardiac hypertrophy that is reversed after 1 week of deacclimation. We propose that autophagy is a major mechanism underlying the heart remodeling seen in response to cold exposure and its posterior reversion after deacclimation.

Seguridad en procedimientos dermatológicos: hemorragia quirúrgica en cirugía dermatológica. Cómo reconocerla, prevenirla y tratarla / Safety in Dermatologic Procedures: How to Prevent, Recognize, and Treat Bleeding Complications in Dermatologic Surgery

Las complicaciones por hemorragia quirúrgica en la cirugía dermatológica son infrecuentes y poco relevantes en la mayoría de los casos. En algunas ocasiones la hemorragia quirúrgica puede conllevar infección de la herida quirúrgica, dehiscencia de sutura o necrosis del colgajo/injerto. En esta revisión se muestran los aspectos más importantes para prevenir, reconocer y tratar este tipo de complicaciones durante el acto quirúrgico y tras él (AU)

Bleeding complications during dermatologic surgery are uncommon and usually minor, but bleeding occasionally leads to infection, wound dehiscence, or flap/graft necrosis. This review covers the keys to preventing, recognizing, and treating excessive bleeding during and after surgery (AU)

[Translated article] Safety in Dermatologic Procedures: How to Prevent, Recognize, and Treat Bleeding Complications in Dermatologic Surgery / Seguridad en procedimientos dermatológicos: hemorragia quirúrgica en cirugía dermatológica. Cómo reconocerla, prevenirla y tratarla

Bleeding complications during dermatologic surgery are uncommon and usually minor, but bleeding occasionally leads to infection, wound dehiscence, or flap/graft necrosis. This review covers the keys to preventing, recognizing, and treating excessive bleeding during and after surgery (AU)

Las complicaciones por hemorragia quirúrgica en la cirugía dermatológica son infrecuentes y poco relevantes en la mayoría de los casos. En algunas ocasiones la hemorragia quirúrgica puede conllevar infección de la herida quirúrgica, dehiscencia de sutura o necrosis del colgajo/injerto. En esta revisión se muestran los aspectos más importantes para prevenir, reconocer y tratar este tipo de complicaciones durante el acto quirúrgico y tras él (AU)