Surgical Management of Comminuted Midshaft Clavicle Fractures Using Reconstruction Plate and Circumferential Wiring: Does the Circumferential Wiring Interfere with the Bone Union? / 대한정형외과학회잡지

Purpose@#This study examined the radiological and clinical outcomes of internal fixation using a reconstruction plate and 21G circumferential wire in comminuted midshaft clavicular fractures. @*Materials and Methods@#A retrospective cohort study was performed on 51 patients between 2005 and 2019. Thirty-two patients underwent internal fixation with a reconstruction plate and a 21G circumferential wire with minimal soft tissue detachment, and 19 patients underwent surgery without a wire. The patients were assessed with the radiographic parameters, the University of California at Los Angeles (UCLA) score, and the visual analogue scale (VAS) pain score. Based on this, patients who operated without a circumferential wire were set as the control group, and the differences in bone union between the two groups were compared. @*Results@#Thirty-two patients were followed-up for an average of 65 weeks, and 19 patients in the control group were followed-up for an average of 56 weeks. The radiological evaluation confirmed the anatomical reduction and bone union in all 32 patients. No case of nonunion was present. The UCLA score was 32.38 on average and 33.11 in the control group (p=0.395). The VAS score was 1.00 on average and 0.84 in the control group (p=0.668). A significant difference in the bony union time was observed between the group who underwent internal fixation with a reconstruction plate and a 21G circumferential wire with minimal soft tissue detachment, and the control group (p=0.015). On the other hand, there was no statistical significance when other variables were controlled (p=0.107). @*Conclusion@#For displaced midshaft clavicular fractures, internal fixation using a reconstruction plate and 21G circumferential wire maintained accurate anatomical reduction. The satisfactory clinical and radiological results mean that internal fixation using a reconstruction plate and 21G circumferential wire may be a good option for surgical treatment.

Early Onset Subsequent Vertebral Compression Fracture after Percutaneous Verteroplasty / 대한정형외과학회잡지

PURPOSE: To evaluate the characteristics and the risk factors of early onset subsequent vertebral compression fractures after percutaneous vertebroplasty. MATERIALS AND METHODS: A total of 44 patients, who had a new subsequent vertebral fracture after percutaneous vertebroplasty for an osteoporotic vertebral compression fracture between January 2013 and December 2015, were recruited. The patients were divided into two groups according to the onset period of subsequent fracture. The number of patients who had a fracture within 3 months following vertebroplasty were 22 cases (Group A); after 3 months were 22 cases (Group B). Variables, including age, sex, bone mineral density (BMD), body mass index (BMI), preexisting vertebral compression fracture, location of the initial fracture, intradiscal cement leakage, injected cement volume, restoration of vertebral body height, and correction of kyphosis, in the two groups were analyzed and compared retrospectively. RESULTS: The age, sex, BMD, BMI, preexisting vertebral compression fracture, location of the initial fracture, intradiscal cement leakage, and correction of kyphosis were similar in the two groups. Both a greater volume of bone cement injected and a greater degree of vertebral height restoration contributed significantly to the risk of fracture within 3 months. CONCLUSION: The cement volume and degree of height restoration are risk factors for early onset fracture at the adjacent vertebrae after percutaneous vertebroplasty and close attention is needed during the follow-up period.

A phase 1/2a, dose-escalation, safety and preliminary efficacy study of oral therapeutic vaccine in subjects with cervical intraepithelial neoplasia 3 / 부인종양

OBJECTIVE: Persistent infection of HPV increases the chance of carcinoma in situ of cervix through stages of cervical intraepithelial neoplasia (CIN) 1, 2, and 3, and finally progresses into cervical cancer. We aimed to explore the safety and efficacy of BLS-M07 which is orally administered agent expressing human papillomavirus (HPV) 16 E7 antigen on the surface of Lactobacillus casei in patients with CIN 3. METHODS: Patients with CIN 3 were recruited in our clinical trial. Reid Colposcopic Index (RCI) grading and serum HPV16 E7 specific antibody production were used to evaluate efficacy of BLS-M07. In phase 1, BLS-M07 was administered orally, 5 times a week, on weeks 1, 2, 4, and 8 with dosages of 500 mg, 1,000 mg, and 1,500 mg. In phase 2a, patients were treated with 1,000 mg. The primary endpoints were the safety and the pathologic regression on colposcopic biopsy. RESULTS: Nineteen patients were enrolled in the CIN 3 cohort. In phase 1, no patients experienced dose limiting toxicity. No grade 3 or 4 treatment-related adverse events or deaths were observed. At 16 weeks after treatment, RCI grading was improved and serum HPV16 E7 specific antibody production increased (p<0.05). Six of 8 (75%) patients with CIN 3 were cured in phase 2a. CONCLUSIONS: Oral immunization with BLS-M07 increases production of serum HPV16 E7 specific antibody which induces protective humoral immunity. The safety of this oral vaccine was proved and could be a competitive non-surgical therapeutic agent of CIN 3. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02195089

Serratia marcescens Spinal Epidural Abscess Following Caudal Epidural Injection / 대한정형외과학회잡지

Spinal infection due to Serratia marcescens is very rare. A 78-year-old male patient withoutany risk factor was admitted to our hospital with chief complaints of severe back pain, fever, weakness in both legs, and bowel dysfunction, following caudal epidural injection. Magnetic resonance imaging revealed spondylodiscitis with epidural abscess. Surgical decompression was performed and the epidural abscess was removed. The cultures isolated S. marcescens, which can cause nosocomial infection in immunocompromised patient. However, to the best of our knowledge, we report the first case of S. marcescens spinal epidural abscess following epidural injection, with literature review.

PI3K and ERK signaling pathways are involved in differentiation of monocytic cells induced by 27-hydroxycholesterol

27-Hydroxycholesterol induces differentiation of monocytic cells into mature dendritic cells, mDCs. In the current study we sought to determine roles of the PI3K and the ERK pathways in the 27OHChol-induced differentiation. Up-regulation of mDC-specific markers like CD80, CD83 and CD88 induced by stimulation with 27OHChol was significantly reduced in the presence of LY294002, an inhibitor of PI3K, and U0126, an inhibitor of ERK. Surface expression of MHC class I and II molecules elevated by 27OHChol was decreased to basal levels in the presence of the inhibitors. Treatment with LY294002 or U0126 resulted in recovery of endocytic activity which was reduced by 27OHChol. CD197 expression and cell adherence enhanced by 27OHChol were attenuated in the presence of the inhibitors. Transcription and surface expression of CD molecules involved in atherosclerosis such as CD105, CD137 and CD166 were also significantly decreased by treatment with LY294002 and U0126. These results mean that the PI3K and the ERK signaling pathways are necessary for differentiation of monocytic cells into mDCs and involved in over-expression of atherosclerosis-associated molecules in response to 27OHChol.

Inhibitory Effects of Methanol Extract from Nardostachys chinensis on 27-hydroxycholesterol-induced Differentiation of Monocytic Cells

27-Hydroxycholesterol (27OHChol) has been reported to induce differentiation of monocytic cells into a mature dendritic cell phenotype. We examined the effect of methanol extract of Nardostachys chinensis (Nard) on 27OHChol-induced differentiation using THP-1, a human monocytic cell line. Treatment of monocytic cells with methanol extract of Nard resulted in decreased transcription and surface expression of CD80, CD83, and CD88 elevated by 27OHChol in a dose-dependent manner. Surface levels of MHC class I and II molecules elevated by 27OHChol were also reduced to basal levels by treatment with the Nard extract. Decreased endocytosis activity caused by 27OHChol was recovered by treatment with the Nard extract. CD197 expression and cell attachment were attenuated by the Nard extract. In addition, levels of transcription and surface expression of CD molecules involved in atherosclerosis, such as CD105, CD137, and CD166 upregulated by 27OHChol were significantly decreased by treatment with methanol extract of Nard. These results indicate that methanol extract of Nard down-regulates 27OHChol-induced differentiation of monocytic cells into a mature dendritic cell phenotype and expression of CD molecules associated with atherosclerosis. The current study suggests that biological activity of oxygenated cholesterol derivatives can be inhibited by herbal medication.

Diclofenac Inhibits 27-hydroxycholesterol-induced Differentiation of Monocytic Cells into Mature Dendritic Cells

We investigated whether diclofenac could influence the development of antigen-presenting cells in an oxygenated cholesterol-rich environment by determining its effects on the 27-hydroxycholesterol (27OHChol)-induced differentiation of monocytic cells into mature dendritic cells (mDCs). Treatment of human THP-1 monocytic cells with diclofenac antagonized the effects of 27OHChol by attenuating dendrite formation and cell attachment and promoting endocytic function. Diclofenac inhibited the transcription and surface expression of the mDC markers of CD80, CD83, and CD88, and reduced the 27OHChol-induced elevation of surface levels of MHC class I and II molecules to the basal levels in a dose-dependent manner. It also reduced the expression of CD197, a molecule involved in DC homing and migration. These results indicate that diclofenac inhibits the differentiation of monocytic cells into mDCs, thereby potentially modulating adaptive immune responses in a milieu rich in cholesterol oxidation products.

Popliteal sciatic nerve block versus spinal anesthesia in hallux valgus surgery / 대한마취과학회지

BACKGROUND: We compared clinical properties and patient satisfaction between spinal anesthesia and popliteal sciatic nerve block (PSNB) for hallux valgus surgery. METHODS: Forty patients undergoing hallux valgus surgery were divided into spinal group (spinal anesthesia with 2.5 ml of 0.5% bupivacaine [n = 20]) and PSNB group (PSNB with 30 ml of 0.75% ropivacaine mixed with 10 ml of normal saline solution using a nerve stimulator [n = 20]). The PSNB group used a patient-controlled-analgesia (PCA) pump for postoperative pain control. The quality and side effects were compared between the two groups. A questionnaire was used to evaluate patient satisfaction with the use of anesthetic techniques and postoperative pain control in the PSNB group. This study was assessed 3 days postoperatively by a blinded observer. RESULTS: Procedure time and time from anesthesia until start of sugery were significantly shorter in the spinal group than those in the PSNB group (P < 0.01). Anesthesia-related complications such as hypotension, bradycardia, shivering, nausea/vomitting, post-dural puncture headache (PDPH) and urinary retension were observed in 15%, 10%, 5%, 5%, 10%, and 20% of patients in the spinal group, respectively. PSNB was not associated with these complications. Patient satisfaction was slightly higher for PSNB than for spinal anesthesia. In the PSNB group, patient satisfaction with postoperative pain-control was 95% above ordinary satisfaction. CONCLUSIONS: Despite the long duration of the procedure, PSNB is relatively safe, provides an adequate level of anesthesia, effectively controls postoperative pain and reduces side effects. Therefore, PSNB could be a potential anesthetic technique for hallux valgus surgery.

Pneumomediastinum after functional endoscopic sinus surgery under general anesthesia: A case report / 대한마취과학회지

The occurrences of pneumothorax and pneumomediastinum are rare, but considered to be potentially life-threatening conditions in patients undergoing functional endoscopic sinus surgery under general anesthesia. Tracheobronchial rupture may results in serious complications, such as pneumothorax and pneumomediastinum. It may occur accidentally by endotracheal tube when the patient's neck is flexed or extended. We report the case of a 48-year-old female patient who developed massive subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum seven hours after functional endoscopic sinus surgery under general anesthesia.

The relationship between the predictors of obstructive sleep apnea and difficult intubation / 대한마취과학회지

BACKGROUND: The study was performed in order to determine the risk factors for difficult tracheal intubation in obstructive sleep apnea patients. METHODS: For 115 male patients with obstructive sleep apnea syndrome and who were undergoing palatal muscle resection (PMR), we investigated the correlation between their age, height, weight, body mass index (BMI), their Epworth Sleepiness Scale (ESS), their apnea-hypopnea index (AHI), their neck circumference and the difficulty of tracheal intubation. RESULTS: The factors significantly related to difficult tracheal intubation in obstructive sleep apnea patients were a high AHI and a large neck circumference. There was no significant correlation between weight, BMI, arterial hypertension, ESS and difficult tracheal intubation in obstructive sleep apnea patients. CONCLUSIONS: In this study, a high AHI and a large neck circumference can predict difficult tracheal intubation in obstructive sleep apnea patients.

Green urine in a patient who received a continuous infusion of propofol: A case report / 대한마취과학회지

The color of urine in patients who receive anesthetic gives much medical information to a medical team. So, we must check the urine color and know the cause of discoloration of the urine from anesthetic patients. Green urine is rare indeed and it is a benign potential side effect of propofol; this phenomenon is related to the metabolism of propofol. We experienced green urine from a long-term anesthetized patient who received a continuous infusion of propofol. We report here on this unusual case and we review the relevant literature.

Comparison of time to awareness between obese patients and non-obese patients after total intravenous anesthesia with propofol and remifentanil

BACKGROUND: The rate of obesity has reached epidemic proportions and is on the rise.There have not been adequate studies on the differences in anesthesiology in obese patient. For this reason, we designed this study to determine the effect of obesity on time to awareness, comparing the use of propofol and remifentanil in general anesthesia. METHODS: We enrolled 55 patients into the study, between ages 16 and 45 years, who had an ASA physical status 1, 2 and who were undergoing general anesthesia for an elective obstetric operation. According to the Asia-Pacific obesity criteria, we divided the patients into 2 groups, the obesity group (BMI > or = 25), and the non-obesity group (BMI < 25). Propofol and remifentanil were infused using TCI for general anesthesia. The bispectral index score (BIS) was used for monitoring depth of anesthesia.During each operation, we tried to keep the BIS between 40 and 55 by controling the target concentration of TCI.We compared the time-to- awareness between the obese patient group and the non-obese patient group. RESULTS: The obesity and the non-obesity group did not show significant difference in awareness times between the obesity group, 412.4 +/- 102.5 s and the non-obesity group, 434.1 +/- 49.1 s. CONCLUSIONS: There was no evidence of a significant difference in time-to-awareness between the obese patient group and the non-obese patient group.The use of remifentanil and propofol work equally well in obese and in non-obese patients anesthesized for elective surgery.

Expression of Angiogeneis-related Factors in Retinal Pigment Epithelial Cells under Hypoxia

PURPOSE: To elucidate the mechanism of neoangiogenesis of human retinal pigment epithelium (HRPE) under hypoxia. METHODS: HRPE cells were cultured for 2 and 24 hours in a hypoxic chamber. Expression and production of the angiogenic factor, vascular endothelial growth factor (VEGF) and the anti-angiogenic factor, pigment epithelium-derived factor (PEDF) were analyzed by RT-PCR and Western blot, respectively. Neoangiogenesis was induced by adding culture supernatant harvested from cells exposed to hypoxic conditions. Neoangeogenesis was measured with a tube formation assay that uses ECV 304 cells and with a migration assay that uses human dermal microvascular endothelial cells. RESULTS: Competitive RT-PCR showed that the expression of the PEDF gene in HRPE cells under hypoxic state decreased compared to normoxic state (p<0.01) but the expression of the VEGF gene increased (p<0.01) when exposed to hypoxic conditions. These results corresponded to those of the Western blot analysis which revealed a significant increase of VEGF production (p<0.01) and a decrease of PEDF production (p<0.01). Moreover, the tube formation and migration assays demonstrated that angiogenesis was increased by exposure to hypoxic stress. Taken together, HRPE cells under hypoxic stress produce more VEGF and less PEDF, which lead to neoangiogenesis. CONCLUSIONS: These results suggest that the subretinal neovascularization that occurs under hypoxic stress might be caused by an imbalance of angiogenesis-related factors in HRPE cells.

A Comparative Study of Recovery Characteristics between Propofol-Remifentanil and Sevoflurane-Nitrous Oxide Anesthesia in Children / 대한마취과학회지

BACKGROUND: Remifentanil and sevoflurane are characterized by rapid emergence from anesthesia. Therefore, propofol-remifentanil anesthesia (PR) and sevoflurane-nitrous oxide anesthesia (SN) were compared with regard to the recovery characteristics in children. METHODS: Sixty children scheduled for tonsillectomy were randomly assigned to receive PR (n = 30) or SN (n = 30). The PR group was induced by remifentanil, propofol and vecuronium, maintained with infusion of remifentanil and propofol. The SN group was induced by sevoflurane, nitrous oxide, vecuronium maintained with sevoflurane in 50% nitrous oxide. At the end of operation, all anesthetics were discontinued and 100% oxygen was inspirated in both groups. The times to spontaneous breathing, extubation, eye opening, PACU discharge were assessed and postoperative nausea/vomiting, agitation were noted. RESULTS: Spontaneous breathing occurred after 9.29 +/- 1.02 minutes (PR) versus 6.85 +/- 0.60 minutes (SN) (P < 0.05), extubation after 9.19 +/- 0.91 minutes versus 8.87 +/- 0.67 minutes, eye opening after 9.47 +/- 1.01 minutes versus 14.85 +/- 0.80 minutes (P < 0.05) and PACU discharge after 21.32 +/- 2.01 minutes versus 27.55 +/- 1.72 minutes (P < 0.05). The occurrence of postoperative nausea/vomiting was 7% (PR) versus 13% (SN), and the incidence of agitation was 60% (PR) versus 83% (SN). CONCLUSIONS: It was observed that the recovery of propofol-remifentanil anesthesia was faster than that of sevoflurane-nitrous oxide anesthesia, except spontaneous breathing. The incidences of postoperative nausea/vomiting were low in both groups, and the incidences of agitation were higher in SN group than in PR group.

Appropriate Dose of Remifentanil for the Prevention of Emergence Agitation after Total Intravenous Anesthesia (TIVA) in Pediatric Patients Undergoing Tonsillectomy

BACKGROUND: Pediatric tonsillectomy may be associated with a high incidence of emergence agitation. The aim of this study was to determine the appropriate dose of remifentanil continuously administered in the postanesthetic care unit (PACU) to reduce the incidence of emergence agitation and side effects after total intravenous anesthesia (TIVA). METHODS: Sixty children aged from 4 to 12 years undergoing tonsillectomy were randomly assigned to 3 groups. Anesthesia was induced with 1.5 mg/kg of propofol, 1microg/kg of remifentanil and was maintained with continuous infusion of propofol 100microg/kg/min, remifentanil 0.25microg/kg/min. At the end of surgery, each group received 0.025 (group 1), 0.05 (group 2), or 0.1 (group 3)microg/kg/min of remifentanil, respectively and the infusion was discontinued at 10 min before PACU discharge. Duration of anesthesia and emergence time were evaluated at the operating room. Agitation score, the time of stay in PACU and postoperative side effects were evaluated at the PACU. RESULTS: The emergence time and the time of stay in PACU were prolonged in the group 3 compared to the other groups (P < 0.05). The Group 2 and 3 had lower agitation score in comparison with that of the group 1 in the PACU (P < 0.05). CONCLUSIONS: For reducing emergence agitation after TIVA, we recommend infusion dose of remifentanil 0.05microg/kg/min.

Effect of Oxidative Stress on the Expression of Gelatinases in Cultured RPE

PURPOSE: To evaluate the expression pattern of gelatinases in the human retinal pigment epithelial cell line ARPE-19 in response to oxidative stress. METHODS: ARPE-19 cells were exposed to paraquat for 72 hours. The cells were assayed for the mRNA expression of gelatinase A and gelatinase B by reverse transcriptase polymerase chain reaction (RT-PCR). The conditioned media were assayed for the production of gelatinases protein by Western blotting. Also, the inhibitory effect of the antioxidants against oxidative stress to the cells was evaluated. RESULTS: The gelatinase levels in the RPE cells increased under oxidative stress compaired with the control (p<0.05). Also, the levels decreased when the cells were incubated with the antioxidant N-acetylcysteine (NAC). CONCLUSIONS: Oxidative stress upregulates gelatinase expression in ARPE-19 cells.

A Case of Tubeculous Neuroretinitis

OBJECTIVE: Tuberculosis is a chronic infection caused by Mycobacterium tuberculosis that can appear throughout the entire body; however, intraocular tuberculosis is rare. We report a case of tuberculous neuroretinitis accompanied by periphlebitis. METHODS: A 17-year-old female was referred with the diagnosis of retinal vasculitis. In the fundus of her right eye, an edematous disc, serous detachment of the macula, multiple hard exudates, and vascular sheathing around the veins were noted. Also, she had no direct light reflex in her right eye. Although her chest X-ray showed no abnormalities, the Tuberculin test was positive; therefore, the condition was diagnosed with a neuroretinitis accompanied by periphlebitis caused by Mycobacterium tuberculosis. RESULTS: High-dose steroid treatment decreased peripapillary edema but did not improved visual acuity. Treatment with antituberculosis medicine resulted in the recovery of her visual acuity and in fundus changes. CONCLUSIONS: Ocular tuberculosis commonly appears as perivasculitis; however, it can cause a visual disturbance by invading the retina and optic nerve simultaneously.

Phosphatidylinositol-3-kinase Inhibitor Enhances Nitric Oxide Synthesis and Apoptosis in LPS-Stimulated Macrophages / 대한해부학회지

Phosphatidylinositol-3-kinase (PI3-kinase) is critical player in cell proliferation and death. The mechanism by which bacterial lipopolysaccharide (LPS) induces synthesis of nitric oxide (NO) in murine macrophages is incompletely understood. In this study we examined the effects of wortmannin and LY294002, two inhibitors of PI3-kinase, on the induction of NO synthesis and NO-mediated apoptosis in LPS-stimulated macrophages. Treatment of wortmannin and LY294002 markedly potentiated NO synthesis and inducible NO synthase (iNOS) expression in LPS-stimulated cells. Furthermore, wortmannin also enhanced apoptosis in LPS-stimulated cells. These results suggest that PI3-kinase might play an important role in transducing the signal that involved in LPS-induced macrophage activation.

Effects of Oral Administration of Phellinus linteus on the Productions of the Th1- and Th2-type Cytokines in Mice

BACKGROUND: The mushroom Phellinus linteus (PL) has been shown to have the anti-tumor and immunostimulatory effects. We hypothesized that the hot water extract of PL (WEPL) exerts its significant immunostimulatory effect by inducing production of the Th1-derived cytokine interferon-gamma (IFN-gamma) by T lymphocytes. METHODS: T lymphocytes were isolated from the mice fed with 200 mg/kg of WEPL once a day for 4 weeks, and then stimulated with the mitogen concanavaline A (Con A). IFN-gamma gene and intracellular protein expressions were analyzed by RT-PCR and flow cytometry, respectively. The production of IFN-gamma was measured by enzyme-linked immunosorbent assay. RESULTS: WEPL significantly enhanced the transcription of IFN-gamma mRNA. The effect of WEPL on IFN-gamma expression was further supported by a concomitant increase in the number of cells with intracellular IFN-gamma protein as well as the secretion of IFN-gamma. However, WEPL did not modulate either gene expression or protein secretion of interleukin-4, a Th2-associated cytokine, by Con A-stimulated T lymphocytes. CONCLUSION: Our results demonstrate that one of the potentially beneficial anti-tumor and immunostimulatory effects of WEPL may be mediated through the enhancement of IFN-gamma secretion by T lymphocytes.

The Effectiveness of Low Dose Fentanyl Bolus Injection in Cesarean Section after Umbilical Cord Clamping / 대한마취과학회지

BACKGROUND: For anesthesia in cesarean section N2O and low concentrations of inhalation anesthetics are regarded as the anesthetic agent of choice. But a low level of anesthesia frequently leads to increased maternal hemodynamic responses and awareness. The effects of a 3 microgram/kg fentanyl bolus injection after umbilical cord clamping was evaluated in 20 full-term parturients, scheduled for elective cesarean section, versus to 20 parturients without fentanyl. METHODS: The forty parturients (ASA physical status 1, 2) scheduled for cesarean section were randomized to either a N2O-enflurane (E group) or a N2O-enflurane-fentanyl (F group). Thiopental sodium (4 mg/kg) and succinylcholine (1.5 mg/kg) were administered intravenously for the induction and endotracheal intubation. Anesthesia was maintained with 50% N2O and 1% enflurane in oxygen until delivery. After delivery, the intravenous injection of 0.5 mg/kg of atracurium was administered, controlled ventilation was applied to maintain PetCO2 at 30 to 35 mmHg with N2O (3 L/min) and O2 (1.5 L/min). Immediately after clamping the umbilical cord, 3 microgram/kg of fentanyl (F group only) was administered. Heart rate, blood pressure, awareness, recovery time, postoperative complication and recall were evaluated. RESULTS: Heart rate values at 10 and 20 min after umbilical cord clamping and 5 min after extubation, and mean arterial pressure at 5, 10 and 20 min after umbilical cord clamping in group F were found to be significantly lower than in group E. CONCLUSIONS: We conclude that N2O-enflurane-fentanyl at 3 microgram/kg is clinically satisfactory in anesthesia for cesarean section, having no adverse effects on the mother.