Intraoperative bladder visualization by indocyanine green filling and subsequent washout in endoscopic hysterectomy: ICG-Washout method.

INTRODUCTION: Despite a potential risk of bladder injury in laparoscopic hysterectomy (LH) and robot-assisted LH (RaLH), an intraoperative method for delineating the entire bladder with indocyanine green (ICG) has not been established. METHODS: We conducted a preliminary experiment using porcine bladders to verify the appropriate amount of ICG for intraoperative bladder visualization. Afterward, intraoperative bladder visualization was tried in LH and RaLH in two patients suspected of having adhesions around the bladder after previous abdominal surgery. RESULTS: Although near-infrared (NIR) fluorescence was well observed through the wall of the porcine bladder filled with ICG solution at a concentration of 0.024 mg/mL, the subsequent replacement of the ICG solution with saline made the NIR fluorescence brighter. In both patients, the bladder was successfully delineated by NIR fluorescence after filling the bladder with ICG solution and the subsequent washout with saline. CONCLUSION: The ICG-Washout method for locating the bladder by NIR fluorescence could be useful in LH and RaLH.

Successful control of menstrual cycle-related exacerbation of inflammatory arthritis with GnRH agonist with add-back therapy in a patient with rheumatoid arthritis.

Patients with rheumatoid arthritis may demonstrate fluctuations in arthritis symptoms associated with the menstrual cycle. This is the first case report of successful control of menstrual cycle-related exacerbation of rheumatoid arthritis with a gonadotropin-releasing hormone agonist and add-back therapy. A 49-year-old premenopausal woman experienced recurrent severe arthritis flares despite aggressive immunotherapy. Her arthritis symptoms started 10 days before her menstruation and spontaneously resolved after the initiation of menstruation. We chose a gonadotropin-releasing hormone agonist with percutaneous estradiol gel to prevent a hypoestrogenic state and a levonorgestrel-releasing intrauterine system to facilitate uterine protection by estrogen. Thereafter, her symptoms significantly improved without experiencing major flares. In addition, she did not demonstrate any menopausal symptoms. This case highlights that rheumatoid arthritis disease activity may be associated with the menstrual cycle, and hormonal therapy may be beneficial as an adjunct therapy for controlling premenstrual exacerbation of rheumatoid arthritis.

Exogenous oxytocin used to induce labor has no long-term adverse effect on maternal-infant bonding: Findings from the Japan Environment and Children's Study.

BACKGROUND: This study investigated the association between exogenous oxytocin use for labor induction and adverse maternal-infant bonding (MIB). METHODS: Data on 19 700 mother-infant pairs were collected, in which the infants were live-birth singletons, born in cephalic position and at >37 weeks of gestation; the drug used to induce labor was noted. Between 2011 and 2014, Japanese pregnant women were enrolled in a nationwide prospective birth cohort study, the Japan Environment and Children's Study. The Japanese version of the Mother-to-infant Bonding Scale (MIBS-J) was administered and demographic information was collected through medical record transcripts. MIBS-J scores were obtained at one month, six months, and one year after delivery. We estimated the risk of adverse MIB between use of oxytocin and other methods for labor induction using multiple linear regression analyses; interaction and mediation analyses to assess the relationship among MIBS-J scores also followed. RESULTS: Exogenous oxytocin was used during labor on 15 252 (77.4%) participants. After adjusting for confounders, there were no significant differences in adverse MIB between groups for which exogenous oxytocin was used and not used for labor induction. LIMITATION: The MIBS-J scores at one and six months were compiled using five instead of 10 questions. Moreover, detailed information was unavailable; for example, the questionnaire did not ask for the dosage and timing of the drugs used to induce labor. CONCLUSIONS: Exogenous oxytocin is a safe and vital drug to induce labor, and has been shown in this study to have no significant impact on long-term adverse MIB.

Catalytic C(sp2)-C(sp3) Bond Formation of Methoxyarenes by the Organic Superbase t-Bu-P4.

The organic superbase catalyst t-Bu-P4 achieves nucleophilic aromatic substitution of methoxyarenes with alkanenitrile pronucleophiles. A variety of functional groups [cyano, nitro, (non)enolizable ketone, chloride, and amide moieties] are allowed on methoxyarenes. Moreover, an array of alkanenitriles with/without an aryl moiety at the nitrile α-position can be employed. The system also features no requirement of a stoichiometric base, MeOH (not salt waste) formation as a byproduct, and the production of congested quaternary carbon centers.

Catalytic Amination of ß-(Hetero)arylethyl Ethers by Phosphazene Base t-Bu-P4.

We describe the catalytic amination of ß-(hetero)arylethyl ethers with amines using the organic superbase t-Bu-P4 to obtain ß-(hetero)arylethylamines. The reaction has a broad substrate scope and allows the transformations of electron-deficient and electron-neutral ß-(hetero)arylethyl ethers with various amines including pyrrole, N-alkylaniline, diphenylamine, aniline, indole, and indoline derivatives. Mechanistic studies indicate a two-reaction pathway of MeOH elimination from the substrate to form a (hetero)arylalkene followed by the hydroamination of the alkene.

Organic Superbase t-Bu-P4 Catalyzes Amination of Methoxy(hetero)arenes.

We report that the organic superbase t-Bu-P4 efficiently catalyzes the amination of methoxy(hetero)arenes with amine nucleophiles such as aniline, indoline, and aminopyridine derivatives. This catalytic reaction is effective for the transformation of electron-deficient methoxyarenes possessing diverse functionalities (carbonyl, cyano, nitro, and halogen) as well as methoxyheteroarenes, including pyrazine, quinoline, isoquinoline, and pyridine derivatives. Intramolecular reactions provide six- and seven-membered ring cyclic amine products.

Phosphazene Base tBu-P4 Catalyzed Methoxy-Alkoxy Exchange Reaction on (Hetero)Arenes.

The organic superbase tBu-P4 catalyzes methoxy-alkoxy exchange reactions on (hetero)arenes with alcohols. The catalytic reaction proceeded efficiently with electron-deficient methoxy(hetero)arenes as well as with a variety of alcohols, including 3-amino-1-propanol, ß-citronellol, menthol, and cholesterol. An intramolecular version of this reaction furnished six- and seven-membered ring compounds.

Comparison of endometriotic cysts and ovarian cancer in association with endometriotic cysts.

OBJECTIVE: The aim of this study was to clarify the clinical, laboratory, and imaging findings of ovarian cancer in association with endometriotic cysts by detailed comparison of the findings of benign and malignant tumors. METHODS AND MATERIALS: This was a retrospective study of 138 women who had an operation for ovarian tumors at the Department of Obstetrics and Gynecology of Kochi Health Sciences Center between September 1, 2011, and July 30, 2015. The ovarian tumors were divided into two groups: the benign group (endometriotic cysts) and the malignant group (ovarian cancer in association with endometriotic cysts). RESULTS: Of the 138 patients, 28 had malignant disease, and 110 had benign endometriotic cysts. Patients in the malignant group were significantly older than patients in the benign group. The mean maximum tumor diameter was also significantly larger for the malignant tumors. Unilocular-solid and multilocular-solid type tumors were present in 25.0% and 75.0% of malignant tumors, and in 9.1% and 19.1% of benign tumors, respectively. The mean maximum solid component diameter and height were significantly larger in the malignant tumors than in the benign tumors. The solid components were present on the abdominal side of the cyst wall in 12.5% of benign tumors and in 51.9% of malignant tumors. CONCLUSION: In elderly patients, the presence of large solid components in large endometriotic cysts, especially the abdominal side of the cyst wall, might suggest malignancy. MICRO ABSTRACT: The aim of this study was to clarify the findings of ovarian cancer in association with endometriotic cysts by detailed comparison of the findings of benign and malignant tumors. The presence of solid components in large endometriotic cysts, especially the abdominal side of the cyst wall, might suggest malignancy.

Impact of chorioamnionitis on short- and long-term outcomes in very low birth weight preterm infants: the Neonatal Research Network Japan.

OBJECTIVE: To evaluate the short- and long-term outcomes among very low birth weight (VLBW) preterm infants after histologic chorioamnionitis (HCA). METHODS: We performed a retrospective analysis of 5849 single infants (birth weight <1500 g) born at a gestational age between 22 + 0 and 33 + 6 weeks. Clinical data were obtained from the Neonatal Research Network Japan between 2003 and 2007. Multivariable logistic regression analyses were performed to assess the effect of HCA on short- and long-term outcome. RESULTS: According to logistic regression analysis, HCA was associated with lower incidence of respiratory distress syndrome (odds ratio [OR] = 0.54; p < 0.001), increased chronic lung disease (OR = 1.68; p < 0.001) and sepsis (OR = 1.71; p < 0.001) and as a short-term outcomes. There was no significant association with intraventricular hemorrhage (OR = 1.11; p = 0.33), periventricular leukomalacia (OR = 1.07; p = .070) and death before discharge (OR = 0.97; p = 0.084). HCA was associated with increased home oxygen therapy (OR = 3.09; p < 0.001), but not with cerebral palsy (CP; OR = 0.91; p = 0.63), develop quotient < 70 (OR = 1.27; p = 0.17), visual impairment (OR = 1.08; p = 0.77), severe hearing impairment (OR = 1.28; p = 0.62) and death (OR = 0.98; p = 0.91) before three years of age. CONCLUSIONS: In this retrospective population-based study in Japan, HCA was not a risk factor for death, neurodevelopmental impairment and CP in VLBW three-year-old preterm infants.

Emergency surgery for tubo-ovarian abscess identified extended-spectrum beta-lactamase-producing Escherichia coli: the first case presentation revealing causative bacteria.

We report herein a 41-year-old female with a tubo-ovarian abscess (TOA), which microbial cultures showed to contain extended-spectrum beta-lactamase (ESBL)-producing E. coli, a causative agent of community-acquired infection. The patient initially presented with acute abdominal pain and back pain. Pelvic computed tomography and transvaginal ultrasonography revealed multiple cystic lesions in the bilateral ovaries that suggested TOA. An emergency laparotomy was therefore performed due to the potential for life-threatening septic shock from the TOA-associated pelvic inflammatory disease. Microbial cultures of postoperative fluid discharge from the placed intra-abdominal catheter, vaginal secretions, urine, blood, and feces detected ESBL-producing E.coli. In summary, we successfully performed emergency surgery for life-threatening septic TOA caused by ESBL-producing E. coli infection.

Long-term outcomes of antenatal corticosteroids treatment in very preterm infants after chorioamnionitis.

PURPOSE: To evaluate the effect of antenatal corticosteroids (AC) therapy on short- and long-term outcomes among very low birth weight preterm infants after histologic chorioamnionitis (HCA). METHODS: We performed a retrospective analysis of 5240 single very low birth weight (VLBW) infants born at 22 + 0 and 33 + 6 weeks of gestation between 2003 and 2007, who registered to the Neonatal Research Network Japan. The effects of AC therapy on mortality, neurodevelopmental outcomes at 3 years of age and neonatal morbidities were analyzed in the groups with or without HCA using logistic regression analysis. RESULTS: In the study subjects, 840 were with HCA, 2734 were without HCA, and 1666 were excluded without data for HCA. AC therapy was significantly associated with decreasing mortality before 3 years of age; [0.52 (0.32-0.86)], [odds ratio (95 % confidence intervals]. There were no differences between the two groups regarding neurodevelopmental outcomes, including cerebral palsy [0.90 (0.41-1.99)], development quotient <70 [0.93 (0.48-1.81)], visual impairment [0.46 (0.04-5.18)], and severe hearing impairment [4.00 (0.30-53.4)] in the group with HCA as well as without HCA. Regarding neonatal morbidities, AC therapy was associated with a lower incidence of respiratory distress syndrome [0.67 (0.50-0.91)], sepsis [0.62 (0.41-0.94)], late-onset adrenal insufficiency [0.62 (0.39-0.98)] and an increased incidence of chronic lung disease [1.62 (1.18-2.24)] in the group with HCA. In the group without HCA, AC therapy was associated with decreasing respiratory distress syndrome [0.60 (0.43-0.84)] and increasing chronic lung disease [1.34 (1.11-1.62)]. CONCLUSION: AC therapy is significantly associated with reduced mortality before 3 years of age in VLBW infants with HCA, but not with neurodevelopmental outcomes, which was same as the results found in infants without HCA. AC therapy is recommended for women with suspected chorioamnionitis, as well as those without chorioamnionitis.

The Effects of Antenatal Corticosteroids on Short- and Long-Term Outcomes in Small-for-Gestational-Age Infants.

AIM: To evaluate the effect of antenatal corticosteroids (ANS) on short- and long-term outcomes in small-for-gestational age (SGA) infants. METHODS: A retrospective database analysis was performed. A total of 1,931 single infants (birth weight <1,500 g) born at a gestational age between 22 weeks and 33 weeks 6 days who were determined to be SGA registered in the Neonatal Research Network Database in Japan between 2003 and 2007 were evaluated for short-term outcome and long-term outcome. RESULTS: ANS was administered to a total of 719 infants (37%) in the short-term outcome evaluation group and 344 infants (36%) in the long-term outcome evaluation group. There were no significant differences between the ANS group and the no-ANS group for primary short-term outcome (adjusted odds ratio (OR) 0.73; 95% confidence interval (CI) 0.45-1.20; P-value 0.22) or primary long-term outcome (adjusted OR 0.69; 95% CI 0.40-1.17; P-value 0.17). CONCLUSIONS: Our results show that ANS does not affect short- or long-term outcome in SGA infants when the birth weight is less than 1500 g. This study strongly suggests that administration of ANS resulted in few benefits for preterm FGR fetuses.

Human leukocyte antigen-G, a ligand for the natural killer receptor KIR2DL4, is expressed by eutopic endometrium only in the menstrual phase.

OBJECTIVE: To investigate menstrual cycle changes in expression by eutopic endometrium of a nonclassic human leukocyte antigen, HLA-G, which binds to the killer immunoglobulin-like receptor (KIR) 2DL4 (CD158d) on natural killer (NK) cells. Such antigens have been linked to endometriosis. DESIGN: Case-control study. SETTING: University hospital. PATIENT(S): We examined 20 Japanese women undergoing hysterectomy for endometriosis and 17 undergoing hysterectomy for myoma. INTERVENTION(S): Immunohistochemical HLA-G staining of eutopic endometrium and peritoneal fluid (PF) cells from women with and without endometriosis. Flow cytometric analysis of PF NK cells from women with and without endometriosis. MAIN OUTCOME MEASURE(S): HLA-G staining in eutopic endometrium was quantified by image analysis. The KIR2DL4-expressing NK cells in PF were investigated by flow cytometry. RESULT(S): The HLA-G was expressed by eutopic endometrium only in the menstrual phase and not in the late proliferative or secretory endometrium. Intensity of HLA-G staining did not differ significantly between women with and without endometriosis. The HLA-G- expressing cells were detected in PF during the menstrual period. These cells are morphologically and flow cytometrically different from mesothelial cells and NK cells. CONCLUSION(S): The HLA-G expression is observed in eutopic endometrium only during the menstrual phase, and no differences were observed between women with and without endometriosis. Epithelial cells bearing HLA-G may enter the peritoneal cavity during retrograde menstruation, allowing the antigen to react locally with KIR2DL4.

Decreased human leukocyte antigen-DR expression in the lipid raft by peritoneal macrophages from women with endometriosis.

OBJECTIVE: To investigate the macrophage response in endometriosis by determining the expression and localization of human leukocyte antigen (HLA)-ABC and HLA-DR by the peritoneal fluid (PF) macrophages and PF concentrations of interferon (IFN)-gamma that regulate HLA expression. DESIGN: Case-control study. SETTING: University hospital. PATIENT(S): 64 Japanese endometriosis patients, and 65 women with other laparoscopic diagnoses. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): Expression and localization of HLA-ABC and HLA-DR in PF macrophages were determined by flow cytometry and confocal microscopy. The concentration of IFN-gamma in PF was determined by enzyme-linked immunosorbent assay. RESULT(S): In women with endometriosis, expression of HLA-ABC and HLA-DR by PF macrophages, and the IFN-gamma concentrations in PF were statistically significantly lower than in controls. Women with endometriosis showed a statistically significant positive correlation between HLA expression and IFN-gamma concentration. By confocal microscopy, HLA-ABC was distributed homogenously on the macrophage surface whereas HLA-DR expression on these cells corresponded to the lipid raft. CONCLUSION(S): In women with endometriosis, low HLA expression and particularly reduced HLA-DR in the lipid raft may be influenced by low IFN-gamma and may compromise antigen presentation, limiting the immune response to peritoneal cavity antigens such as implanted or metaplastic endometrial tissue.

Killer immunoglobulin-like receptor and human leukocyte antigen expression as immunodiagnostic parameters for pelvic endometriosis.

PROBLEM: We investigated host immunologic responses to endometriosis by comparing immune cell surface antigens in peripheral blood (PB) and peritoneal fluid (PF) from women with endometriosis with those in PB and PF from other patients. METHOD OF STUDY: Japanese women with endometriosis (n = 56) were compared with controls with other laparoscopic diagnoses (n = 68). PB and PF were collected at the time of laparoscopy for flow cytometry. RESULTS: No significant difference in phenotypic parameters of T cells (CD3, CD4, and CD8), B cells (CD19), natural killer (NK) cells (CD56), or monocytes/macrophages (CD14) was seen between women with and without endometriosis. However, increased killer immunoglobulin-like receptor (CD158a) expression by NK cells and decreased human leukocyte antigen (HLA)-ABC and -DR expression by macrophages, all suggesting decreased functional activation were found in endometriosis. These markers showed significant association with endometriosis by odds ratio, logistic regression, and decision tree analyses. CONCLUSIONS: Increased CD158a(+) NK cells in PB and PF indicated decreased NK cell cytotoxicity in endometriosis, while decreased HLA expression on PF macrophages suggested impaired antigen presentation. Thus, aberrant immune responses by NK cells and macrophages may represent risk factors for endometriosis.

Human leukocyte antigen expression by peritoneal macrophages from women with pelvic endometriosis is depressed but coordinated with costimulatory molecule expression.

OBJECTIVE: To investigate the macrophage response in endometriosis, we determined expression of human leukocyte antigen (HLA)-ABC, HLA-DR, and their costimulatory molecules by peritoneal fluid (PF) macrophages. DESIGN: Case-control study of immunologic markers. SETTING: University hospital. PATIENT(S): We compared 38 Japanese women with endometriosis with 59 control subjects who were given other laparoscopic diagnoses. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): Expression of HLA-ABC, HLA-DR, CD54, CD40, CD58, CD80, and CD86 by peripheral blood (PB) monocytes and PF macrophages was quantitated as mean fluorescence intensities by flow cytometry. Expression of each marker on PF macrophages was divided by that on PB monocytes as an index of macrophage activation (macrophage activation ratio). RESULT(S): In women with endometriosis, PF macrophages showed significant positive correlations between expression of HLA-ABC and other costimulatory molecules and also between HLA-DR and their costimulatory molecules. However, expression of HLA-ABC and DR by PF macrophages, and also their activation ratios, were significantly lower than in controls. CONCLUSION(S): Coordination with costimulatory molecules but relatively low expression of HLA-ABC and HLA-DR indicates a positive but limited immune response (antigen presentation) to events in the peritoneal cavity in women with endometriosis. This may induce immune tolerance to implanted or metaplastic endometrial tissue.