Role of lateral suspension for the treatment of pelvic organ prolapse: a Delphi survey of expert panel.

INTRODUCTION AND HYPOTHESIS: Lateral suspension is an abdominal prosthetic surgical procedure used to correct apical prolapse. The procedure involves the placement of a T-shaped mesh on the anterior vaginal wall and on the isthmus or uterine cervix that is suspended laterally and posteriorly to the abdominal wall. Since its description in the late 90s, modifications of the technique have been described. So far, no consensus on the correct indications, safety, advantages, and disadvantages of this emerging procedure has been reached. METHODS: A modified Delphi process was used to build consensus within a group of 21 international surgeons who are experts in the performance of laparoscopic lateral suspension (LLS). The process was held with a first online round, where the experts expressed their level of agreement on 64 statements on indications, technical features, and other aspects of LLS. A subsequent re-discussion of statements where a threshold of agreement was not reached was held in presence. RESULTS: The Delphi process allowed the identification of several aspects of LLS that represented areas of agreement by the experts. The experts agreed that LLS is a safe and effective technique to correct apical and anterior prolapse. The experts highlighted several key technical aspects of the procedure, including clinical indications and surgical steps. CONCLUSIONS: This Delphi consensus provides valuable guidance and criteria for the use of LLS in the treatment of pelvic organ prolapse, based on expert opinion by large volume surgeons' experts in the performance of this innovative procedure.

Easy and Efficient Recovery of EMIMCl from Cellulose Solutions by Addition of Acetic Acid and the Transition from the Original Ionic Liquid to an Eutectic Mixture.

Ionic liquids (ILs) and deep eutectic solvents (DESs) are the two most widely used neoteric solvents. Recently, our group described how the simple addition of acetic acid (AcOH) to 1-Ethyl-3-methylimidazolium chloride (EMIMCl) could promote the transition from the original IL to an eutectic mixture of EMIMCl and AcOH. Herein, we studied how cellulose regeneration and EMIMCl recovery from EMIMCl solutions of cellulose could be benefited by the significant differences existing between EMIMCl- and EMIMCl·AcOH-based mixtures and the easy switching from one to the other. Finally, we also demonstrated that the transition could also be accomplished by addition of acetic anhydride and water so that the process could be eventually useful for the achievement of highly acetylated cellulose.

Can the simultaneous laparoscopic approach improve the learning of vaginal surgery with meshes in the anatomical model?

AIMS: To evaluate the usefulness of simultaneous laparoscopic assistance to improve understanding of the nonvisible surgical steps in Thiel-embalmed cadaver models for training in vaginal surgery using vaginal mesh kits and to evaluate opinions of this surgical learning procedure in comparison with other learning models. METHODS: Recording of anterior compartment prolapse repair with vaginal mesh kits using an external camera simultaneously with laparoscopic vision during the execution of the procedure at the dissection room. To measure the usefulness of this procedure, we designed an anonymous online survey that was made available to program participants via a computer application (a link to video 1 and the survey is available at encuesta@um.es). RESULTS: After watching the video, 97.2% of participants agreed that laparoscopic vision combined with the vaginal approach was useful in learning this surgical technique, and 95.8% agreed they had learned details of the surgical anatomy of the pelvis. All participants agreed that it should be mandatory to train in these techniques with cadavers before practice with live patients. In addition, 84.7% responded that the cadaveric model was superior to animal and other types of models. CONCLUSION: Laparoscopic inspection of the procedure performed with the vaginal approach allowed a better understanding of the surgical technique by making "visible" the anatomical structures that were commonly only palpated. Use of the cadaverous model was considered most efficient for training in this surgical technique.

Clinical pilot study to evaluate the neovaginal PACIENA prosthesis® for vaginoplasty without skin grafts in women with vaginal agenesis.

BACKGROUND: To evaluate the feasibility and clinical outcomes of vaginoplasties using a neovaginal polylactic acid prosthesis made with 3-dimensional (3D) printing technology as an intraneovaginal mould. METHODS: This was an interventionist, prospective, and multicentre clinical pilot investigation of a sanitary product (PACIENA prosthesis®) aiming to recruit and operate on 8 patients over 6 months with a follow-up period of 6 months. Only six patients with Rokitansky syndrome and one patient with Morris syndrome (7 patients in total) were operated on in two university hospitals: "La Fe", Valencia (H1) and "Arrixaca", Murcia (H2). INTERVENTIONS: Extensive surgical dissection of a defined space between the urethra and bladder in the front and of the rectum in the back as well as insertion of the PACIENA prosthesis® covered with Interceed® were performed. After 12 days, the prosthesis was changed to the silicone-covered version for daily application. RESULTS: In the 6 patients with Rokitansky syndrome (86%), the primary endpoint (satisfactory vaginal outcome in terms of appearance, function, and sensation without relevant additional morbidity) was achieved, although only 2 patients (28%) were sexually active at the end of 6 months of follow-up. The patient with Morris syndrome withdrew from the study after 1 month. Patients without bacterial colonization showed positive Schiller tests at 1 month, and subsequent biopsies showed adequate keratinization and epidermization. Epithelization and iodopositivity were delayed in the patients who developed inflammatory granulomas. CONCLUSIONS: Good anatomical and functional results can be achieved with the PACIENA prosthesis® for vaginoplasties without skin grafts. However, adequate patient selection and education, good surgical techniques and haemostasis, postoperative support, and prevention of bacterial colonization are important. TRIAL REGISTRATION: This clinical study was approved by the Ethical Clinical Investigation Committee of San Juan University Hospital on September 27, 2016, to be conducted in the participating centres; it was authorized by the Spanish Agency of Medicines and Health Products (AEMPS) on April 24, 2017 (exp. no. 585/16/EC), to be carried out in that hospitals.

Which Low-Abundance Proteins are Present in the Human Milieu of Gamete/Embryo Maternal Interaction?

The improvement of the embryo culture media is of high relevance due to its influence on successful implantation rates, pregnancy, neonatal outcomes, and potential effects in adult life. The ideal conditions for embryo development are those naturally occurring in the female reproductive tract, i.e., the oviductal and uterine fluids. To shed light on the differences between chemical and natural media, we performed the first comparative study of the low abundance proteins in plasma, uterine, and oviductal fluid collected, simultaneously, from healthy and fertile women that underwent a salpingectomy. The rationale for this design derives from the fact that high-abundant proteins in these fluids are usually those coming from blood serum and frequently mask the detection of low abundant proteins with a potentially significant role in specific processes related to the embryo-maternal interaction. The proteomic analysis by 1D-nano LC ESI-MSMS detected several proteins in higher amounts in oviductal fluid when compared to uterine and plasma samples (RL3, GSTA1, EZRI, DPYSL3, GARS, HSP90A). Such oviductal fluid proteins could be a target to improve fertilization rates and early embryo development if used in the culture media. In conclusion, this study presents a high-throughput analysis of female reproductive tract fluids and contributes to the knowledge of oviductal and uterine secretome.

Vesicouterine fistula: teaching video on diagnosis and surgical treatment.

INTRODUCTION: A 42-year-old woman presented with urinary incontinence 9 years after the last of four vaginal deliveries. She had also had one Caesarean section. Immediately after the last delivery, she presented with haematuria, which resolved within a few hours, but the drain remained prophylactically for 7 days. Nine years later, she was referred to a specialist hospital. METHOD: The patient presented with continuous urinary incontinence, and physical examination revealed a loss of urine from the vagina, the latter confirmed by a methylene blue test showing loss of urine from the uterine cervix. Other diagnostic techniques used were cystography, cystoscopy and uro-CT. Based on a literature review of the management options for such patients and the relevant clinical details of our patient, a decision was made to perform a total abdominal hysterectomy and fistula repair. RESULTS AND DISCUSSION: Six months following surgery, the results were entirely satisfactory, with full urinary continence and significant improvement in the patient's quality of life. A discussion about controversial approaches to diagnosis and management is included.

Central pontine myelinolysis during pregnancy: Pathogenesis, diagnosis and management.

Central pontine myelinolysis (CPM) is a rare condition usually caused by rapid sodium correction in hyponatraemia after a severe neurological syndrome. Only few cases have been reported during pregnancy, most of which were reported in patients with hyperemesis. We describe the successful management of the first case of twin pregnancy in a patient who presented with CPM after treatment for premature labour and then review the literature on CPM in pregnancy (aetiology, diagnosis and management). Our patient required emergency delivery to achieve electrolyte and fluid balance. At six months, the twins remained asymptomatic and the mother had minor sequelae. The aetiology is not clear, and there is no evidence regarding the optimal treatment or prognosis of CPM. In our patient, desmopressin-contaminated atosiban showed a certain probability in the Karch-Lasagne algorithm of a causality relationship between hyponatraemia and the drug. To our knowledge, this is the first case of myelinolysis reported in a twin pregnancy possibly related to desmopressin-contaminated atosiban.

Caesarean delivery: conflicting interests.

Within the maternal-fetal relationship, interests may sometimes diverge. In this paper, a pregnant woman's refusal to undergo a caesarean delivery, which was recommended both to save the life of the fetus and to minimize risks to her, is described. The legal aspects involved in the conflict between maternal autonomy and fetal well-being are analysed. The patient requested an abortion because of the poor condition of the fetus; however, according to Spanish legislation, the possibility of abortion was rejected as the pregnancy was in its 27th week. The woman still persisted in her refusal to accept a caesarian delivery. After the medical team sought guidance on the course to follow, the Duty Court authorized a caesarean delivery against the wishes of the patient. From a legal point of view, at stake were the freedom of the woman - expressed by the decision to reject a caesarean delivery - and the life of the unborn child. In clinical treatment, the interests of the fetus are generally aligned with those of the pregnant woman. When they are not, it is the pregnant woman's autonomy that should be respected, and coercion should form no part of treatment, contrary to the decision of this court.

Preparation of chitosan nanocomposites with a macroporous structure by unidirectional freezing and subsequent freeze-drying.

Chitosan is the N-deacetylated derivative of chitin, a naturally abundant mucopolysaccharide that consists of 2-acetamido-2-deoxy-ß-d-glucose through a ß (1→4) linkage and is found in nature as the supporting material of crustaceans, insects, etc. Chitosan has been strongly recommended as a suitable functional material because of its excellent biocompatibility, biodegradability, non-toxicity, and adsorption properties. Boosting all these excellent properties to obtain unprecedented performances requires the core competences of materials chemists to design and develop novel processing strategies that ultimately allow tailoring the structure and/or the composition of the resulting chitosan-based materials. For instance, the preparation of macroporous materials is challenging in catalysis, biocatalysis and biomedicine, because the resulting materials will offer a desirable combination of high internal reactive surface area and straightforward molecular transport through broad "highways" leading to such a surface. Moreover, chitosan-based composites made of two or more distinct components will produce structural or functional properties not present in materials composed of one single component. Our group has been working lately on cryogenic processes based on the unidirectional freezing of water slurries and/or hydrogels, the subsequent freeze-drying of which produce macroporous materials with a well-patterned structure. We have applied this process to different gels and colloidal suspensions of inorganic, organic, and hybrid materials. In this review, we will describe the application of the process to chitosan solutions and gels typically containing a second component (e.g., metal and ceramic nanoparticles, or carbon nanotubes) for the formation of chitosan nanocomposites with a macroporous structure. We will also discuss the role played by this tailored composition and structure in the ultimate performance of these materials.

Uterine rupture in twin pregnancy with normal fetus and complete hydatidiform mole.

We describe a rare case of complete hydatidiform mole with twin live fetus (CHMTF) confirmed by histopathology, flow cytometry and polymerase chain reaction techniques. No malformations were observed, fetal karyotype was normal and ß-human chorionic gonadotropin levels were high (>100,000 IU/ml). The patient was informed of the risks and decided to continue with the pregnancy, but at week 15, she had to undergo hysterectomy due to uterine rupture. She subsequently developed persistent trophoblastic disease (PTD) with pulmonary metastases that required treatment with polychemotherapy. Patients with CHMTF should be informed of all known risks, including the considerable risk of PTD, which is similar to or, even higher than that associated with a singleton complete mole. The risk does not appear to be increased by continuing the pregnancy. Because so few series have been published, there is a lack of evidence-based clinical management guidelines. To our knowledge, this is the first report of uterine rupture in CHMTF.

Recycling and reutilization of metals aided by deep eutectic solvents: from NMC cathodes of spent Li-ion batteries to electrolytes for supercapacitors.

With the rapidly increasing demand for lithium ion batteries (LIBs), recycling the metals found in spent cathodes is mandatory to both alleviate shortages resulting from the mining of natural metal ores and manage the disposal of spent LIBs.  The use of deep eutectic solvents (DESs) for metals recovery from spent cathodes of LIBs (e.g., LCO and NMC types) offers a sustainable yet efficient alternative to conventional hydrometallurgical processes. Nonetheless, further efforts are required to use milder temperatures and higher mass loadings, thus ensuring cost-effectiveness. In this latter regard, addressing the reutilization of DESs in subsequent stages of metal extraction, and streamlining or eliminating the chemical procedures employed for metal separation, is even more crucial to guarantee the economic feasibility of the recycling process. Herein, we have prepared a DES that provides extraction efficiencies of ca. 100% for every metal of NMC cathodes even at mild experimental conditions (e.g., 60 °C) and for loadings as high as 70 mgNMC/gDES.  Moreover, we have pioneered the direct use of leachates containing DESs and metals as electrolytes for supercapacitors. This approach enables the reintroduction of DESs and the recovered metals into the value chain with a minimal economic and environmental impact.

Association between Coffee Consumption and Polycystic Ovary Syndrome: An Exploratory Case-Control Study.

Polycystic ovary syndrome (PCOS) is a leading cause of infertility, with an estimated worldwide prevalence between 5% and 15%. We conducted a case-control study with 121 PCOS patients and 155 controls to assess the association between coffee intake and the presence of having a diagnosis of PCOS in women in Murcia, Spain. The PCOS diagnosis was determined following Rotterdam criteria (the presence of two of the following three conditions: hyperandrogenism, oligo-anovulation, and/or polycystic ovarian morphology). Coffee consumption was assessed using a validated food frequency questionnaire. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multiple logistic regression. Coffee consumption was categorized into never, less than one cup per day, one cup per day, and two or more cups per day. We found a significant inverse linear trend: the higher the coffee consumption, the lower the probability of having PCOS in multivariable analysis (p-trend = 0.034). Women who presented with PCOS were less likely to drink one cup of coffee compared to those who had never drunk coffee (OR = 0.313, 95% CI: 0.141-0.69). The consumption of at least one cup of coffee per day may be associated with a decrease in PCOS symptoms.

Deep-eutectic solvents playing multiple roles in the synthesis of polymers and related materials.

The aim of this review is to provide an exposition of some of the most recent applications of deep-eutectic solvents (DESs) in the synthesis of polymers and related materials. We consider that there is plenty of room for the development of fundamental research in the field of DESs because their compositional flexibility makes the number of DESs susceptible of preparation unlimited and so do the range of properties that DESs can attain. Ultimately, these properties can be transferred into the resulting materials in terms of both tailored morphologies and compositions. Thus, interesting applications can be easily envisaged, especially in those fields in which the preparation of high-tech products via low cost processes is critical. We hope that the preliminary work surveyed in this review will encourage scientists to explore the promising perspectives offered by DESs.

Management of a dichorionic twin pregnancy with a normal fetus and an androgenetic diploid complete hydatidiform mole.

We describe a rare case of complete hydatidiform mole with twin live fetus (CHMTF) confirmed by histopathology, flow cytometry, and polymerase chain reaction techniques. No malformations were observed, fetal karyotype was normal and ß-human chorionic gonadotropin levels were increased (>100,000 IU/ml). Once the patient had been informed of the risks, it was decided to continue the pregnancy, but termination of pregnancy was necessary at week 13 + 5 due to maternal complications consisting of hyperthyroidism, hypertension and vaginal bleeding, followed by persistent trophoblastic disease (PTD). Patients diagnosed with CHMTF should be informed of all known risks, including the considerable risk of PTD, which is similar to - or according to some reports - even higher than that associated with a singleton complete mole and is not increased by continuing pregnancy. Due to the low number of series published, evidence-based clinical management guidelines are lacking.

The female upper reproductive tract harbors endogenous microbial profiles.

Introduction: The female reproductive tract harbours unique microbial communities (known as microbiota) which have been associated with reproductive functions in health and disease. While endometrial microbiome studies have shown that the uterus possesses higher bacterial diversity and richness compared to the vagina, the knowledge regarding the composition of the Fallopian tubes (FT) is lacking, especially in fertile women without any underlying conditions. Methods: To address this gap, our study included 19 patients who underwent abdominal hysterectomy for benign uterine pathology, and 5 women who underwent tubal ligation as a permanent contraceptive method at Hospital Clínico Universitario Virgen de la Arrixaca (HCUVA). We analyzed the microbiome of samples collected from the FT and endometrium using 16S rRNA gene sequencing. Results: Our findings revealed distinct microbiome profiles in the endometrial and FT samples, indicating that the upper reproductive tract harbors an endogenous microbiome. However, these two sites also shared some similarities, with 69% of the detected taxa Being common to both. Interestingly, we identified seventeen bacterial taxa exclusively present in the FT samples, including the genera Enhydrobacter, Granulicatella, Haemophilus, Rhizobium, Alistipes, and Paracoccus, among others. On the other hand, 10 bacterial taxa were only found in the endometrium, including the genera Klebsiella, Olsenella, Oscillibacter and Veillonella (FDR <0.05). Furthermore, our study highlighted the influence of the endometrial collection method on the findings. Samples obtained transcervically showed a dominance of the genus Lactobacillus, which may indicate potential vaginal contamination. In contrast, uterine samples obtained through hysterescopy revealed higher abundance of the genera Acinetobacter, Arthrobacter, Coprococcus, Methylobacterium, Prevotella, Roseburia, Staphylococcus, and Streptococcus. Discussion: Although the upper reproductive tract appears to have a low microbial biomass, our results suggest that the endometrial and FT microbiome is unique to each individual. In fact, samples obtained from the same individual showed more microbial similarity between the endometrium and FT compared to samples from different women. Understanding the composition of the female upper reproductive microbiome provides valuable insights into the natural microenvironment where processes such as oocyte fertilization, embryo development and implantation occur. This knowledge can improve in vitro fertilization and embryo culture conditions for the treatment of infertility.

Crosslinked redox polymer enzyme electrodes containing carbon nanotubes for high and stable glucose oxidation current.

Co-immobilisation approaches for preparation of glucose-oxidising films of [Os(2,2'-bipyridine)(2)(poly-vinylimidazole)(10)Cl] and glucose oxidase on glassy carbon electrodes are compared. Electrodes prepared by crosslinking using glutaraldehyde vapour, without and with a NaBH(4) reduction, provide higher glucose oxidation current than those prepared using a well-established diepoxide method. Addition of multi walled carbon nanotubes to the film deposition solutions produces an enhanced glucose oxidation current density of 5 mA cm(-2) at 0.35 V vs. Ag/AgCl, whilst improving the operational stability of the current signal. Carbon nanotube, glutaraldehyde vapour crosslinked, films on electrodes, reduced by NaBH(4), retain 77% of initial catalytic current over 24 hours of continuous amperometric testing in a 37 °C, 50 mM phosphate buffer solution containing 150 mM NaCl and 100 mM glucose. Potential application of this approach to implantable enzymatic biofuel cells is demonstrated by production of glucose oxidation currents, under pseudo-physiological conditions, using mediating films with lower redox potentials.

Thiel embalming in neonates: methodology and benefits in medical training.

Current teaching and training methods for surgical techniques in the pediatric population involve artificial models (manikins), animals or adult human cadavers embalmed using various techniques. We found no references in the literature concerning the use of the Thiel method in the pediatric population. The aim of this study, therefore, was to assess the viability of using pediatric human cadavers embalmed through Thiel's technique and to compare them with standard pediatric manikins. After donation of a 24-week stillborn, the Thiel technique was carried out for fixation following the usual protocol. A video recording with eye-tracking glasses was used to perform an examination, and techniques. The same procedures were conducted on a pediatric manikin. Medical students, medical residents and physicians were asked to respond to questions in an online survey after being shown the video. A total of 92 responses were obtained. The Thiel-embalmed stillborn was assessed as superior to the manikin in all items. Our study confirmed that this technique is feasible even with extremely small donors. The value of this form of preservation for medical training is not widely known though it is receiving increasing interest. Our results show that Thiel fixation in pediatrics is clearly more highly valued than a manikin and offers great potential. This innovative application of the Thiel method in the pediatric population is technically possible. It poses no additional difficulties and is very positively assessed for undergraduate and postgraduate teaching.

Sedation with Propofol plus Paracetamol in External Cephalic Version: An Observational Study.

Although the influence of neuraxial anesthesia or sedation with remifentanil in external cephalic version (ECV) is widely known, ECV results using propofol have not been previously analyzed. This study aimed to evaluate ECV outcomes when propofol was used. An observational analysis of ECV was performed between 1 January 2018 and 31 December 2020. ECV was accomplished with tocolysis and propofol. One hundred and thirty-one pregnant women were recruited. The propofol mean dose was 156.1 mg (SD 6.1). A cephalic presentation was achieved in 61.1% (80/131) of the pregnant women. In total, 56.7% (38/67) of pregnant women with cephalic presentation at labor had a spontaneous delivery, 26.9% (18/67) had an operative delivery, and an intrapartum urgent cesarean section was performed in 16.4% (11/67). In total, 46 pregnant women (35.9%) were scheduled for an elective cesarean section due to non-cephalic presentation. The emergency cesarean section rate during the following 24 h was 10.7% (14/131). A major ECV complication arose in 15 cases (11.5%). ECV outcomes when propofol was used seems to be similar to those with other anesthetic adjunct, so sedation with propofol could be an adequate option for ECV. More studies are needed to compare its effectiveness with neuraxial techniques.

Fertility preservation in heterotopic cervical pregnancy: what is the best procedure?

We describe a patient who underwent assisted reproduction techniques and was diagnosed with heterotopic cervical pregnancy, and then discuss the management of this entity, which is rare and has no standard protocols. Treatment consisted of intra-arterial methotrexate (50 mg/m(2) body surface area) and simultaneous selective embolization of uterine arteries. The literature is also reviewed to identify other approaches and outcomes.

The Application of a System of Eye Tracking in Laparoscopic Surgery: A New Didactic Tool to Visual Instructions.

Introduction: Laparoscopic surgery is an increasingly used technique, but it requires a high degree of learning, and communication between the operating room crew is considerably difficult. The use of eye tracking has been proposed as a didactic and evaluation tool in several settings, including in laparoscopy in simulators. Objectives: This study aimed to evaluate the usefulness of the use of eye tracking systems (Tobii glasses 2) in laparoscopic surgery as a didactic and assessment tool to improve communication in the operating room and improve patients' security. Methodology: An anonymous survey was sent to the students and medical teachers of a faculty of medicine and practicing doctors and residents. The message contained an explanation about the use of the Tobii glasses, a link to watch the video showing its use in a laparoscopic surgery, and the survey to complete after watching the video. Results: The survey was answered by 113 participants (51.3% medical students, 27.4% medical teachers, 18.6% practicing doctors, and 2.7% medicine residents). Eighty-three percent agreed with the usefulness of the "Tobii glasses" in the operating room for improving communication between the main surgeon and the assistant, for learning complex surgery techniques, for obtaining didactic videos, and for indicating anatomical structures. The item scored worst was the price of the glasses. Conclusions: It is possible to record and project expert gaze patterns in the operating room in real time using the Tobii glasses. This device allows improving communication among the surgical crew and the learning of residents and also improving the security of surgical patients.