Pessary Management Approach Affects Likelihood of Surgery.

IMPORTANCE: It is unknown whether the pessary management type influences the need for surgery. OBJECTIVE: The aim of this study was to evaluate the rate of surgical treatment for pelvic organ prolapse or stress urinary incontinence with the type of pessary management (self-management or office management). STUDY DESIGN: We conducted a retrospective cohort study that included first-time pessary users treated at a tertiary urogynecologic clinic from 2012 to 2014 for pelvic organ prolapse, stress urinary incontinence, or both. For the primary outcome, we explored the relationship between pessary management type and the likelihood of surgery using multivariable Cox proportional hazards models. Secondary outcomes assessed relationships between patient factors (eg, demographics and clinical attributes) and pessary management type using multivariable logistics regression models. RESULTS: There were 218 patients included in our analysis. Of all pessary users, 59 (27.1%) required office management and 159 (72.9%) participated in self-management. Surgery was performed in 22 (35.1%) office-managed patients and 33 (19.3%) self-managed patients. Women who self-managed their pessaries were significantly less likely to undergo surgery than those who received office management (multivariable hazards ratios, 0.416; P = 0.005). In the multivariable logistic regression model for pessary management type, increasing age (odds ratio [OR], 1.098; P ≤ 0.0001), increasing body mass index (OR, 1.078; P < 0.05), and increasing genital hiatus (OR, 1.547; P < 0.05) were associated with increased odds of pessary office management compared with self-management. CONCLUSIONS: In a urogynecology clinic setting, pessary self-management is associated with lower rates of surgical treatment compared with office management. Factors associated with office management include increased age, body mass index, and large genital hiatus.

The discovery of Arylex™ active and Rinskor™ active: Two novel auxin herbicides.

Multiple classes of commercially important auxin herbicides have been discovered since the 1940s including the aryloxyacetates (2,4-D, MCPA, dichlorprop, mecoprop, triclopyr, and fluroxypyr), the benzoates (dicamba), the quinoline-2-carboxylates (quinclorac and quinmerac), the pyrimidine-4-carboxylates (aminocyclopyrachlor), and the pyridine-2-carboxylates (picloram, clopyralid, and aminopyralid). In the last 10 years, two novel pyridine-2-carboxylate (or picolinate) herbicides were discovered at Dow AgroSciences. This paper will describe the structure activity relationship study that led to the discovery of the 6-aryl-picolinate herbicides Arylex™ active (2005) and Rinskor™ active (2010). While Arylex was developed primarily for use in cereal crops and Rinskor is still in development primarily for use in rice crops, both herbicides will also be utilized in additional crops.

History and evolution of surgical ethics: John Gregory to the twenty-first century.

As surgery grew to become a respected medical profession in the eighteenth century, medical ethics emerged as a response to the growing need to protect patients and maintain the public's trust in physicians. The early influences of John Gregory and Thomas Percival were instrumental in the formulation of patient-centered medical ethics. In the late nineteenth century, the modern surgical advances of anesthesia and antisepsis created the need for a discipline of ethics specific to surgery in order to confront new and evolving ethical issues. One of the founding initiatives of the American College of Surgeons in 1913 was to eliminate unethical practices such as fee-splitting and itinerant surgery. As surgery continued to advance in the era of solid organ transplantation and minimally invasive surgery in the latter half of the twentieth century, surgical innovation and conflict of interest have emerged as important ethical issues moving forward into the twenty-first century. Surgical ethics has evolved into a distinct branch of medical ethics, and the core of surgical ethics is the surgeon-patient relationship and the surgeon's responsibility to advance and protect the well-being of the patient.

Thoracic endovascular aortic repair in 300 patients: long-term results.

BACKGROUND: The aim of this analysis was to assess short and mid-term results of patients undergoing thoracic endovascular aortic repair (TEVAR) for 4 different indications. METHODS: From 1996 to 2010, 300 patients (80 female, 220 male, median age 67 years [20 to 88]) underwent TEVAR at our department. Among them were 137 descending thoracic aneurysms (DTA), 80 type B dissections (60 acute, 20 chronic), 59 perforating aortic ulcer (PAU), and 24 traumatic aortic transections (ATAT). Hospital mortality and mid-term survival among different indications for TEVAR were evaluated. RESULTS: Overall hospital mortality in our series was 5% (n = 15). Seven patients with DTA (5%), 4 patients with type B dissections (5%), 2 patients with PAU (3.4%), and 2 ATAT (8%) patients died during their hospital stay. Kaplan-Meier survival analysis revealed significant differences in survival rates according to the various indications for TEVAR (p < 0.001). Overall long-term mortality was 86%, 63%, and 44% at 1, 5, and 10 years. Early and late endoleak rate was 18% and 8%, respectively. CONCLUSIONS: The TEVAR has evolved into a safe and effective therapy for different aortic pathology resulting in promising long-term results. Nevertheless, the indication for TEVAR has direct impact on the success of the procedure. Patients with acute type B aortic dissections and acute traumatic aortic lesions seem to benefit the most from TEVAR.

The effects of ligand exchange and mobility on the peroxidase activity of a bacterial cytochrome c upon unfolding.

The effect on the heme environment upon unfolding Paracoccus versutus ferricytochrome c-550 and two site-directed variants, K99E and H118Q, has been assessed through a combination of peroxidase activity increase and one-dimensional NMR spectroscopy. At pH 4.5, the data are consistent with a low- to high-spin heme transition, with the K99E mutation resulting in a protein with increased peroxidase activity in the absence of or at low concentrations of denaturant. Furthermore, the mobility of the polypeptide chain at pH 4.5 for the wild-type protein has been monitored in the absence and presence of denaturant through heteronuclear NMR experiments. The results are discussed in terms of local stability differences between bacterial and mitochondrial cytochromes c that are inferred from peroxidase activity assays. At pH 7.0, a mixture of misligated heme states arising from protein-based ligands assigned to lysine and histidine is detected. At low denaturant concentrations, these partially unfolded misligated heme forms inhibit the peroxidase activity. Data from the K99E mutation at pH 7.0 indicate that K99 is not involved in heme misligation, whereas histidine coordination is proven by the data from the H118Q variant.

Functional characterization of the evolutionarily divergent fern plastocyanin.

Plastocyanin (Pc) is a soluble copper protein that transfers electrons from cytochrome b(6)f to photosystem I (PSI), two protein complexes that are localized in the thylakoid membranes in chloroplasts. The surface electrostatic potential distribution of Pc plays a key role in complex formation with the membrane-bound partners. It is practically identical for Pcs from plants and green algae, but is quite different for Pc from ferns. Here we report on a laser flash kinetic analysis of PSI reduction by Pc from various eukaryotic and prokaryotic organisms. The reaction of fern Pc with fern PSI fits a two-step kinetic model, consisting of complex formation and electron transfer, whereas other plant systems exhibit a mechanism that requires an additional intracomplex rearrangement step. The fern Pc interacts inefficiently with spinach PSI, showing no detectable complex formation. This can be explained by assuming that the unusual surface charge distribution of fern Pc impairs the interaction. Fern PSI behaves in a similar way as spinach PSI in reaction with other Pcs. The reactivity of fern Pc towards several soluble c-type cytochromes, including cytochrome f, has been analysed by flavin-photosensitized laser flash photolysis, demonstrating that the specific surface motifs for the interaction with cytochrome f are conserved in fern Pc.