Risk of placenta accreta spectrum following myomectomy: a nationwide cohort study.

BACKGROUND: Whether myomectomy increases the risk of placenta accreta spectrum in the following pregnancies remains controversial. OBJECTIVE: This study aimed to investigate the effect of myomectomy on the risk of placenta accreta spectrum in the following pregnancies. Moreover, different methods of myomectomy on the risk of placenta accreta spectrum were explored. STUDY DESIGN: A nationwide cohort study was conducted using data from the Taiwan National Health Insurance Research Database, including all pregnant patients in Taiwan who gave birth between January 2008 and December 2017. A 1:1 propensity score estimation matching was performed for the analysis of myomectomy on the risk of placenta accreta spectrum. Among pregnant patients who received myomectomy, different methods of myomectomy on the risk of placenta accreta spectrum were compared with the control group. RESULTS: Among the 1,371,458 pregnant patients in this study, 11,255 pregnant patients had a history of myomectomy. The risk of placenta accreta spectrum was higher in pregnant patients with a history of myomectomy than in pregnant patients without a history of myomectomy (incidence: 0.96% vs 0.20%; adjusted odds ratio, 2.28; 95% confidence interval, 1.85-2.81; P<.01). Among pregnant patients with a history of myomectomy, 5045 (46.87%) received laparotomic myomectomy, 3973 (36.93%) received laparoscopic myomectomy, and 1742 (16.20%) received hysteroscopic myomectomy. The incidence of placenta accreta spectrum was higher in the hysteroscopic group than in the laparotomic group or the laparoscopic group (1.89% [hysteroscopic group] vs 0.71% [laparotomic group] and 0.81% [laparoscopic group]; P<.05). Compared with patients without a history of myomectomy, the adjusted odds ratio for placenta accreta spectrum was 3.88 (95% confidence interval, 2.68-5.63; P<.05) in the hysteroscopic group. CONCLUSION: Myomectomy, especially hysteroscopic myomectomy, is associated with an increased risk of placenta accreta spectrum in the subsequent pregnancy.

Clinical studies investigating the use of leuprorelin in Asian women with endometriosis: a review.

We aimed to examine how leuprorelin has been studied for the treatment of women with endometriosis in Asia. We conducted a literature search of PubMed, the Cochrane Library and ClinicalTrials.gov. This review includes randomised trials of women with endometriosis treated with leuprorelin in Asia. Phase I-IV clinical trials published between January 1 2000 and December 31 2016 and written in English were included. Four studies were identified, showing that leuprorelin significantly improves pain and quality of life. The oestrone and oestradiol levels are decreased by leuprorelin but can be increased using an 'add-back' therapy with conjugated equine oestrogen and methoxyprogesterone. Menopause is more common in women treated with leuprorelin. The bone mineral density is reduced in women treated with leuprorelin. There are limited studies investigating the use of leuprorelin for the treatment of endometriosis in Asian populations. However, the research that has been conducted supports the use of leuprorelin in an Asian population.

Standardized uptake value and apparent diffusion coefficient of endometrial cancer evaluated with integrated whole-body PET/MR: Correlation with pathological prognostic factors.

PURPOSE: To evaluate the correlation between maximum standardized uptake value (SUVmax ) and minimum apparent diffusion coefficient (ADCmin ) of endometrial cancer derived from an integrated positron emission tomography / magnetic resonance (PET/MR) system and to determine their correlation with pathological prognostic factors. MATERIALS AND METHODS: This prospective study was approved by the Institutional Review Board of the hospital, and informed consent was obtained. Between April and December 2014, 47 consecutive patients with endometrial cancer were enrolled and underwent simultaneous PET/MR examinations before surgery. Thirty-six patients with measurable tumors on PET/MR were included for image analysis. Pearson's correlation coefficient was used to evaluate the correlation between SUVmax and ADCmin of the tumors. The Mann-Whitney U-test was utilized to evaluate relationships between these two imaging biomarkers and pathological prognostic factors. RESULTS: The mean SUVmax and ADCmin were 14.7 ± 7.1 and 0.48 ± 0.13 × 10(-3) mm(2) /s, respectively. A significant inverse correlation was found between SUVmax and ADCmin (r = -0.53; P = 0.001). SUVmax was significantly higher in tumors with advanced stage, deep myometrial invasion, cervical invasion, lymphovascular space involvement, and lymph node metastasis (P < 0.05). ADCmin was lower in tumors with higher grade, advanced stage, and cervical invasion (P < 0.05). The ratio of SUVmax to ADCmin was higher in tumors with higher grade, advanced stage, deep myometrial invasion, cervical invasion, lymphovascular space involvement, and lymph node metastasis (P < 0.05). CONCLUSION: SUVmax and ADCmin of endometrial cancer derived from integrated PET/MR are inversely correlated and are associated with pathological prognostic factors.

Clinical features and outcomes of neck lymphatic metastasis in ovarian epithelial carcinoma.

BACKGROUND: Neck lymph node metastasis (NLNM) in epithelial ovarian cancer (EOC) is rare and treated as advanced stage cancer. However, ovarian cancer with lymphatic metastasis may manifest a different clinical course from peritoneal carcinomatosis. METHODS: The authors retrospectively assessed 20 patients with EOC and pathologically diagnosed as NLNM between January 2001 and December 2010. The patients were divided into two groups according to the time of NLNM identification. Statistical methods included Kaplan-Meier, log-rank, and Cox regression analysis. RESULTS: Eleven patients were diagnosed with NLNM at the same time of surgical exploration of EOC (Group A) and nine patients at cancer recurrence 43.3 months after initial surgery (Group B). In Group A, patients with tumors confined to the pelvic cavity had no recurrence or had isolated lymph node recurrence (ILNR), and survived longer than patients with abdominal tumor spreading (P = 0.0007). In Group B, 2 patients showed ILNR. The median survival time after NLNM was 42 months in Group A and 6 months in Group B (P = 0.01). Cox model demonstrated that non-serous histology, brain metastasis, and NLNM identified at cancer recurrence were major predictors for poor overall survival (Hazard ratio [HR] = 18.67, 6.93, and 4.52; P = 0.01, 0.02, and 0.04, respectively). CONCLUSIONS: A subgroup of EOC patients with NLNM who presented limited pelvic cancer had much better overall survival than patients who had cancer spreading beyond the pelvic cavity or were diagnosed with NLNM at cancer recurrence.

Association between Wakeup Frequency at Night and Atherogenic Dyslipidemia: Evidence for Sex Differences.

AIM: This study aimed to determine whether sleep disturbance, defined as the wakeup frequency at night, is associated with atherogenic dyslipidemia and to explore possible sex differences. METHODS: A total of 1,368 adults aged 19-70 years were included in the study of lifestyles and atherogenic dyslipidemia at the National Taiwan University Hospital in the period of 2008-2012. They completed a questionnaire regarding lifestyle information and sleep quality, including sleep hour duration, use of sleeping pills, and wakeup frequency during nighttime sleep. The measured lipid profiles included total cholesterol, triglycerides, low- and high-density lipoprotein cholesterol (LDL-C and HDL-C, respectively), non-HDL-C, and small dense LDL-C (sdLDL-C). Multivariate logistic regression was performed to determine habitual interrupted sleep and the odds ratio of atherogenic dyslipidemia following adjustment for conventional risk factors and for sex-based subgroup analysis. RESULTS: A wakeup frequency ≥ 3 times per night was independently associated with an increased risk [odds ratio (95% confidence interval)] of dyslipidemia was 1.96 (1.17-3.28), and non-HDL-C ≥ 160 mg/dL was 1.78 (1.09-2.89). A higher wakeup frequency was associated with increased atherogenic dyslipidemia in women than in men. The multivariate adjusted relative risks for non-HDL ≥ 160 mg/dL and cholesterol ≥ 200 mg/dL were 3.05 (1.27-7.34) and 4.01(1.29-12.45) for female individuals with insomnia and those with a wakeup frequency ≥ 2 times per night, respectively. CONCLUSION: A higher wakeup frequency was associated with atherogenic dyslipidemia in Taiwanese adults, particularly in women. This study also provided another evidence of increasing cardiovascular diseases in subjects with habitual interrupted sleep.

Calreticulin promotes tumor lymphocyte infiltration and enhances the antitumor effects of immunotherapy by up-regulating the endothelial expression of adhesion molecules.

Tumor-induced angiogenesis has been shown to suppress immune responses. One mechanism is to suppress leukocyte-endothelial cell interaction by down-regulating the expression of adhesion molecules, such as intercellular adhesion molecule (ICAM)-1, vascular cell adhesion molecule (VCAM)-1 and E-selectin on the tumor endothelium, which enables tumor cells to escape immune surveillance. Calreticulin (CRT), a chaperone protein mainly located in the endoplasmic reticulum, has been shown to exert anti-angiogenic activity and inhibit tumor growth. Here, we demonstrate that in addition to inhibiting angiogenesis, CRT also enhances the expression of both ICAM-1 and VCAM-1 on tumor endothelial cells. This expression results in enhanced leukocyte-endothelial cell interactions and increased lymphocyte infiltration into tumors. Therefore, combining intramuscular CRT gene transfer with intratumoral cytokine gene therapies significantly improves the antitumor effects of immunotherapy by markedly increasing the levels of tumor-infiltrating lymphocytes. This combined treatment increased the levels of infiltrating lymphocytes to those achieved using four times the cytokine dosage. The combined therapy also resulted in lower levels of immunosuppressive molecules and higher levels of activated T-cells in the tumor microenvironment than immunotherapy alone. In conclusion, this study describes a new antitumor mechanism of CRT that involves the up-regulation of tumor endothelial adhesion molecules and the enhanced infiltration of tumor-specific lymphocytes. Thus, CRT treatment can make tumor cells more vulnerable to immunotherapy and improve the therapeutic efficacy of immunotherapy.

Experience in different modes of delivery in twin pregnancy.

BACKGROUND/PURPOSE: Vaginal delivery, compared with Cesarean delivery, remains a less chosen mode of delivery for twin pregnancy. We studied the maternal and perinatal outcomes of twin pregnancy with different modes of delivery. METHODS: A retrospective study with data collected from a regional hospital, including vital twin pregnancies delivered at gestational age of 32 weeks and above. Medical charts were reviewed for prenatal conditions and postpartum outcomes. RESULTS: Ninety-eight pairs of twins were included and 44.9% were delivered via vaginal delivery. Women in the vaginal delivery group were significantly younger (32.5 ±4.3 years versus 34.8 ±4.6 years, p < 0.01), multiparous (34.1% versus 18.5%) and with more twins in vertex-vertex presentation (70.5% versus 33.3%) compared with women in the Cesarean delivery group. There were no differences between maternal postpartum complications and neonatal outcomes in both groups. The outcomes showed longer inter-twin delivery time interval (5.7 ± 5.6 versus 1.5 ± 0.9 min, p < 0.01), less estimated blood loss (198.7 ± 144.1 versus 763.2 ± 332.3 mL, p < 0.01), and shorter maternal hospital stay (3.0 ± 0.5 versus 5.7 ± 0.5 days, p< 0.01) in the vaginal delivery group. Twenty newborns had Apgar score below seven at birth. Logistic regression analysis revealed that low Apgar score was independently related to younger maternal age, maternal obstetric diseases and fetal non-vertex presentation. Gestational weeks and mode of delivery were not related to low Apgar score. CONCLUSION: With careful case selection, vaginal delivery could be safely performed in twin pregnancies with less estimated blood loss and better recovery than Cesarean delivery.

Vaginal birth after cesarean section: Experience from a regional hospital.

OBJECTIVE: Trial of labor after cesarean section (TOLAC) is an option for women with previous cesarean section. However, few women choose this option because of safety concerns. We evaluate the safety and risks associated with TOLAC and the success rate of vaginal birth after cesarean delivery (VBAC). MATERIAL AND METHODS: We reviewed all patients with a history of previous cesarean section that underwent elective repeat cesarean section (ERCS) or TOLAC in a regional teaching hospital from Nov, 2013 to May, 2018. Maternal basic clinical information, intrapartum management, postpartum complications, and neonatal outcomes were analyzed. RESULTS: 199 pregnant women with a history of at least one previous cesarean section were enrolled. 156 women received ERCS and 43 women (21.6%) underwent TOLAC, with 37 (86.0%) who underwent successful VBAC. The VBAC rate was 18.6%. Higher success rate was found in women with previous vaginal birth than in women without vaginal birth (100% vs. 81.8%). One case (2.3%) in the VBAC group was complicated with uterine rupture and inevitable neonatal death during second stage of labor. The uterus was repaired without maternal complications. In another case, the newborn's condition was complicated with low APGAR score (<7) at birth due to maternal chorioamnionitis. Among indications for previous cesarean section, cephalo-pelvic disproportion (CPD) was associated with TOLAC failure and uterine rupture after VBAC. CONCLUSION: VBAC is a feasible and safe option. Modes of delivery should be thoroughly discussed when considering TOLAC for women with history of previous cesarean section due to CPD, considering its association with TOLAC failure in second stage of labor.

Differential expression of hypoxia-inducible factors related to the invasiveness of epithelial ovarian cancer.

Ovarian cancer is the most lethal gynecological cancer, and it is frequently diagnosed at advanced stages, with recurrences after treatments. Treatment failure and resistance are due to hypoxia-inducible factors (HIFs) activated by cancer cells adapt to hypoxia. IGFBP3, which was previously identified as a growth/invasion/metastasis suppressor of ovarian cancer, plays a key role in inhibiting tumor angiogenesis. Although IGFBP3 can effectively downregulate tumor proliferation and vasculogenesis, its effects are only transient. Tumors enter a hypoxic state when they grow large and without blood vessels; then, the tumor cells activate HIFs to regulate cell metabolism, proliferation, and induce vasculogenesis to adapt to hypoxic stress. After IGFBP3 was transiently expressed in highly invasive ovarian cancer cell line and heterotransplant on mice, the xenograft tumors demonstrated a transient growth arrest with de-vascularization, causing tumor cell hypoxia. Tumor re-proliferation was associated with early HIF-1α and later HIF-2α activations. Both HIF-1α and HIF-2α were related to IGFBP3 expressions. In the down-expression of IGFBP3 in xenograft tumors and transfectants, HIF-2α was the major activated protein. This study suggests that HIF-2α presentation is crucial in the switching of epithelial ovarian cancer from dormancy to proliferation states. In highly invasive cells, the cancer hallmarks associated with aggressiveness could be activated to escape from the growth restriction state.

Diagnosis of Peritoneal Tuberculosis from Primary Peritoneal Cancer.

Peritoneal tuberculosis (PTB) is an uncommon extrapulmonary infection mimickng primary peritoneal cancer (PPC). We retrospectively included 23 women with PTB and 47 women with PPC treated in a medical center to study the clinical and radiological features that differentiate PTB from PPC. Body temperature above 38 °C was a unique feature of PTB (34.7% versus 0%, p < 0.001). Body Mass Index (BMI) was lower (21.9 ± 3.7 versus 25.2 ± 4.1, p = 0.003), white blood cell (WBC) count was lower (5179.6 ± 1502.2 versus 7716.2 ± 2741.8, p < 0.001), and CA-125 level was lower (508.0 ± 266.1 versus 2130.1 ± 2367.2 U/mL, p < 0.001) in PTB compared with PPC. Imaging detected more pulmonary infiltration and consolidation (52.2% versus 6.4%, p < 0.001), and less omental/mesentery changes (52% versus 83%, p < 0.001) in PTB compared with PPC. The operated patients received earlier treatment compared to patients without operation (7.9 ± 5.3 days versus 17.2 ± 11.0 days, p = 0.010). In conclusion, fever above 38 °C, lower BMI, lower WBC count, less elevated CA-125 level, and imaging of less omental involvement were features of PTB differentiated from PPC.

IGFBP3 inhibits angiogenesis through intracellular regulation of THBS1 expression.

Insulin-like growth factor binding protein-3 (IGFBP3) has been postulated to be a mediator of growth suppression signaling. It was shown to function as a suppressor of invasion in epithelial ovarian cancer (EOC). In this study, we identified an angiogenesis inhibitor, thrombospondin-1 (THBS1), which correlated with IGFBP3 expression in EOC cells. After restoring IGFBP3 expression in an EOC cell line using an inducible plasmid, the transfectants showed an increase in IGFBP3 associated with a parallel increase in THBS1. IGFBP3 decreased cell capillary tube formation in HUVECs, which was reversed after anti-THBS1 treatment. IGFBP3 also decreased blood vessel development in chick embryo chorioallantoic membrane (CAM) assay, which was reversed after THBS1 silencing using THBS1 siRNA. Heterotransplantation of IGFBP3 transfectants significantly decreased tumor growth and vascular formation. Luciferase promoter assay illustrated that THBS1 promoter was activated in the presence of both intracellular and extracellular IGFBP3. The signal was stronger in intracellular IGFBP3 expression than that in extracellular IGFBP3 neutralization. In conclusion, we have identified a novel association between IGFBP3 expression and THBS1 elevation, which consequently results in a decrease in angiogenesis. IGFBP3 could activate THBS1 through promoter regulation mainly via an intracellular signaling pathway. Such angiogenesis-regulating ability could be associated with tumor progression and may represent a major function of IGFBP3 as an onco-suppressor in the pathogenesis of ovarian cancer.

Single-port laparoscopic hysterectomy for uteri greater than 500 grams.

OBJECTIVES: To study the operative outcomes of single-port laparoscopic hysterectomy in uteri greater than 500 g, using either laparoscopic assisted vaginal hysterectomy (LAVH) or laparoscopic supracervical hysterectomy (LSH). MATERIALS AND METHODS: 78 patients were included in a single institute by a single surgeon from March, 2013 to January, 2018. RESULTS: The median uterine weight was 686.5 g. Larger uterine weight was correlated with longer operative time and greater estimated blood loss. Two types of operations were performed: LAVH (n = 55) or LSH (n = 23). There were no differences in operative time (150.2 ± 45.1 vs. 158.6 ± 82.1, P = 0.66) and estimated blood loss (365.8 ± 298.5 vs. 356.5 ± 46.6, ml, P = 0.94) between LAVH and LSH. However, patients in LAVH had more excess blood loss (>500 mL) compared with LSH (32.7% vs. 21.7%, P = 0.42). In the later study period, the operative time was shorter and complication rates were lower. Such differences were especially significant in the LAVH group. By multiple regression analysis, operative time was independently correlated with age, body mass index, estimated blood loss and uterine weight in LAVH. The correlation between operative time and uterine weight in LSH was attenuated by estimated blood loss. Estimated blood loss was the dominant factor correlated with longer operative time in LSH. CONCLUSIONS: Both LAVH and LSH could be feasible in uteri greater than 500 g. LSH appeared to have less complication and less blood loss than LAVH. Operative time was correlated significantly with bleeding amount. Therefore, better bleeding control and surgical experience were warrants for single-port laparoscopic hysterectomy in uteri greater than 500 g.

Promoter methylation of IGFBP-3 and p53 expression in ovarian endometrioid carcinoma.

BACKGROUND: Insulin-like growth factor binding protein (IGFBP-3) is an antiproliferative, pro-apoptotic and invasion suppressor protein which is transcriptionally regulated by p53. Promoter methylation has been linked to gene silencing and cancer progression. We studied the correlation between IGFBP-3 and p53 expression as well as IGFBP-3 promoter methylation in ovarian endometrioid carcinoma (OEC) by immunohistochemical staining and quantitative methylation-specific PCR (qMSP). Additionally, we assessed the molecular regulatory mechanism of wild type (wt) p53 on IGFBP-3 expression using two subclones of OEC, the OVTW59-P0 (low invasive) and P4 (high invasive) sublines. RESULTS: In 60 cases of OEC, 40.0% showed lower IGFBP-3 expression which was significantly correlated with higher IGFBP-3 promoter methylation. p53 overexpression was detected in 35.0% of OEC and was unrelated to clinical outcomes and IGFBP-3. By Kaplan-Meier analysis, patients with lower IGFBP-3, higher IGFBP-3 promoter methylation, and normal p53 were associated most significantly with lower survival rates. In OEC cell line, IGFBP-3 expression was correlated with IGFBP-3 promoter methylation. IGFBP-3 expression was restored after treatment with a DNA methy-transferase inhibitors (5-aza-deoxycytidine) and suppressed by a p53 inhibitor (pifithrin-alpha). The putative p53 regulatory sites on the promoter of IGFBP-3 were identified at -210, -206, -183 and -179 bases upstream of the transcription start site. Directed mutagenesis at these sites quantitatively reduced the transcription activity of IGFBP-3. CONCLUSION: Our data suggests that IGFBP-3 silencing through IGFBP-3 promoter methylation in the absence of p53 overexpression is associated with cancer progression. These results support a potential role of IGFBP-3 methylation in the carcinogenesis of OEC.

Positive Association Between Small Dense Low-Density Lipoprotein Cholesterol Concentration and Biomarkers of Inflammation, Thrombosis, and Prediabetes in Non-Diabetic Adults.

AIMS: Recent studies suggest elevated levels of small dense low-density lipoprotein cholesterol (sdLDL-C) can predict the risk of incident coronary heart disease (CHD), even in individuals considered to be at low risk for cardiovascular disease(CVD) based on their LDL-C levels. This study aims to prospectively investigate the association between sdLDL-C concentration and traditional and nontraditional CHD risk markers to explore the underlying roles of sdLDL-C in atherogenic processes. METHODS: Between 2009 and 2011, 594 healthy volunteers aged 35-65 years were recruited as control subjects in a study of work-related risk factors and acute CHD. All participants fasted for 12-14 h, and venous blood samples were collected in the morning to measure serum lipid profiles and other CHD-related markers. A standard oral glucose tolerance test was performed on all participants to assess their subclinical diabetes and prediabetes status. RESULTS: There were significantly positive associations between sdLDL-C concentration and traditional (age, smoking and alcohol drinking habit, blood pressure, body mass index (BMI), serum lipid profiles, and diabetes status) and nontraditional risk factors (complete blood counts, (CBC), fibrinogen, high-sensitivity C-reactive protein, and subclinical diabetes status) for CVD. After adjusting for confounding variables which include age, gender, BMI, hypertension, household income, and smoking and alcohol drinking habits, all atherosclerotic risk markers except D-dimer were significantly and positively associated with sdLDL-C. CONCLUSIONS: Our data indicated sdLDL-C is strongly associated with atherosclerotic risk markers, such as inflammation, thrombosis, hematological markers, and prediabetes. This study supports the hypothesis that sdLDL-C is a promising CVD risk biomarker.

SRPX and HMCN1 regulate cancer­associated fibroblasts to promote the invasiveness of ovarian carcinoma.

Cancer­associated fibroblasts (CAFs) are known to be essential in cancer initiation and development. However, the role of CAFs in promoting ovarian cancer (OC) invasion remains to be fully elucidated. To address this in the present study, 49 clinical OC specimens were used to evaluate the roles of CAFs in promoting ovarian tumor migration and invasion and disease progression. It was found that the sushi repeat­containing protein, X­linked (SRPX) and hemicentin 1 (HMCN1) genes were significantly upregulated in CAFs from high­grade serous carcinoma (HGSC) and clear cell carcinoma (CCC) samples, the two major histological types of OC with frequently poor patient survival rates. The short hairpin (sh)RNA­mediated silencing of SRPX and HMCN1 in fibroblasts significantly suppressed the Transwell invasive activities of OC cells. Further experiments showed that SRPX and HMCN1 regulated the invasiveness of OC via the Ras homology family member A (RhoA) signaling pathway in fibroblasts. Therefore, the findings of the present study suggest that targeting the CAF genes, SRPX and HMCN1, can inhibit OC migration and invasion. These data highlight the importance of CAF­OC crosstalk signaling in cancer invasion and demonstrate the potential for improved efficacy of OC treatment by targeting CAF­SRPX/HMCN1.

Phthalate exposure increases subclinical atherosclerosis in young population.

The link between phthalate exposure and the risk of subclinical atherosclerosis in young population remains unclear. This study investigated the association between phthalate exposure and subclinical atherosclerosis, in terms of carotid intima-media thickness (CIMT), in young population. From a nationwide mass urine screening for renal health, conducted in 1992-2000 among school children 6-18 years of age in Taiwan, we recruited 789 subjects to participate in the cardiovascular health examination in 2006-2008. Among them, 787 received measurements of 7 urinary phthalate metabolites and CIMT. Results showed both mean and maximal values of CIMT at all segments of carotid arteries significantly increased with the urinary mono-2-ethylhexyl phthalate (MEHP), ∑ di-(2-ethylhexyl) phthalate (DEHP), and mono-n-butyl phthalate (MnBP) in a dose-response relationship after adjustment for multiple linear regression models. Multivariate logistic regression analysis showed that higher quartiles of urinary concentrations of MEHP, ∑DEHP, and MnBP were associated with a higher risk of thicker CIMT. Compared to subjects with the lowest quartile (Q1) of urinary MEHP, the adjusted odds ratios (95% confidence interval) for thicker CIMT among subjects with higher urinary MEHP were 2.13 (1.18-3.84) at Q2, 4.02 (2.26-7.15) at Q3 and 7.39 (4.16-13.12) at the highest Q4. In conclusion, urinary phthalate metabolites of MEHP, ∑DEHP, and MnBP are strongly associated with CIMT in adolescents and young adults in Taiwan.

GnRHa Before Single-Port Laparoscopic Hysterectomy in a Large Barrel-Shaped Uterus.

BACKGROUND AND OBJECTIVES: Laparoscopic hysterectomy for a large barrel-shaped uterus is difficult. We assessed the feasibility of single-port laparoscopic hysterectomy in a large barrel-shaped uterus after gonadotropin-releasing hormone agonist (GnRHa). METHODS: We retrospectively reviewed 39 patients with a large barrel-shaped uterus who were treated with GnRHa (leuprolide acetate) before single-port laparoscopic hysterectomy. During the same period, 134 patients without GnRHa pretreatment were included as control subjects. RESULTS: Patients with GnRHa treatment had an average increase in hemoglobin of 3.0 mg/dL and a decrease in uterine weight of 330.9 g (40.1%). Ancillary ports were required in 2 patients in the treatment group and none in the control group. There were no differences in uterine weights, operative time, and estimated blood loss in the 2 groups of patients. The estimated average operative time was shortened by 34 min after GnRHa treatment. However, bladder and ureter injuries were marginally higher (10.3% versus 2.2%) and days of hospital stay (3.7 versus 3.1) were significantly longer in the treatment group compared with controls. Complication rates were correlated with previous operative history, pelvic adhesion, and larger uterine weight but not with GnRHa treatment and operative sequence. CONCLUSIONS: GnRHa pretreatment in patients with a large barrel-shaped uterus during SPH is feasible with shortened operative time. However, the higher complication rates in these patients suggest that a weight-reduced barrel-shaped uterus that is achieved with GnRHa treatment could still be difficult and should be handled in cautious.

Effect of simultaneous morcellation in situ on operative time during laparoscopic myomectomy.

BACKGROUND: Laparoscopic myomectomy (LM) is technically difficult and time consuming procedure that requires surgical skill and modifications. The aim of this study was to assess factors which affect operative times in LM. METHODS: From March 2003 to June 2007, 174 women, who underwent LM for symptomatic myomas, were enrolled. Standard LM was performed in the first 4 years and simultaneous morcellation in situ (SMI) method was applied in the fifth year. RESULTS: The mean myoma weight was 213.5 +/- 190.4 g and the mean operative time was 117.0 +/- 39.6 min. No laparoconversions occurred and there was a 2.3% rate of complications. Total myoma weight increased and operative time declined significantly over time. The surgeon's learning curve and the effect of SMI on operative time were identified by establishing a nonlinear multiple regression model. Model assumptions showed little violation by residual plots. Slopes of the average myoma weight (total myoma weight/number of myoma operated) for describing the operative time declined along with the study year, suggesting that operative experience is a major factor influencing operative time. SMI showed a further 19 min reduction in the predicted operative time. CONCLUSIONS: Operative time in LM is dependent on a multitude of factors including surgical experience. Applying SMI during LM is an efficient way to further reduce operative time.

Proton MR spectroscopy in normal breasts between pre- and postmenopausal women: a preliminary study.

OBJECTIVE: The purpose of our study was to assess the differences in the water and lipid fractions and lipid line widths in normal breasts between premenopausal and postmenopausal women using single-voxel proton MR spectroscopy (1H-MRS). MATERIALS AND METHODS: Thirty-two premenopausal and 25 postmenopausal women were enrolled in the study. Single-voxel proton MR spectroscopy of the breast was performed using point-resolved spectroscopy (PRESS) with water suppression and stimulated echo acquisition mode (STEAM). On STEAM, water fraction 1 was the ratio of the integration of water to the sum of the integration of water and methylene resonances, and the lipid fraction 1 was the ratio of the integration of methylene to water and methylene resonances. Lipid fraction 2 was the ratio of the integration of allylic methylene to water and allylic methylene resonances. Lipid line width was measured on PRESS. RESULTS: The premenopausal group had a higher water fraction 1 and lower lipid fraction 1 than the postmenopausal group (p < 0.01, Student's t test). The breast density had a positive effect on water fraction 1 and a negative effect on lipid fraction 1 for premenopausal women (p = 0.018, multivariate regression) and for the total population (p = 0.019). The premenopausal women had a higher lipid fraction 2 than postmenopausal women without significance (Student's t test), but the premenopausal status had a positive effect on lipid fraction 2 (p = 0.024, multivariate regression). There was no significant correlation between all independent variables and lipid line width. CONCLUSION: Breast 1H-MRS shows the differences of water and lipid compositions between pre- and postmenopausal women. Lipids containing methylene and allylic methylene protons had different implications in normal breasts.