Factors associated with an unfavorable clinical course in hospitalized patients with pelvic inflammatory disease: a retrospective cohort study of 117 patients from a Japanese academic institution.

BACKGROUND: This study aimed to determine the factors associated with an unfavorable clinical course (emergency surgery and/or prolonged hospitalization) in patients requiring hospitalization owing to pelvic inflammatory disease (PID). METHODS: A retrospective study was performed on 117 patients diagnosed with PID who were admitted to our hospital between January 2014 and December 2018. Multivariate regression analysis was conducted to determine the factors associated with emergency surgical intervention, and prolonged hospitalization in a subgroup of successful expectant management (n = 93). RESULTS: The average age (mean ± standard deviation) of the patients was 41.2 ± 12.5 years; 16 (13.7%) were postmenopausal; 81 patients (69.2%) complicated with a tubo-ovarian abscess (TOA) of which 59 (72.9%) had an ovarian endometrioma; and 19 patients (16.2%) had a history of various intrauterine manipulations. Emergency surgery was performed in 24 patients (20.5%), and patients with TOA underwent emergency surgery more often than did patients without TOA (25.9% vs. 8.3%, p = 0.03), and TOA was associated with longer length of hospital stay (17.1 days vs. 8.0 days, p = 0.01). Smoking, postmenopausal status, past medical history of PID, and high C-reactive protein (CRP) level at admission were significantly associated with emergency surgery. In patients with successful expectant management, obesity (body mass index ≥ 30) and high WBC and CRP level at admission were significantly associated with prolonged hospitalization. CONCLUSIONS: Of the patients requiring hospitalization owing to PID, TOA was associated with both emergency surgery and prolonged hospital stay. Patients with increased inflammatory markers and obesity should be considered to be at a high risk for unfavorable clinical course in the management of PID.

Ultrasonographic evaluation of pelvic floor structure at antepartum and postpartum periods using three-dimensional transperineal ultrasound.

PURPOSE: To examine the changes in the pelvic floor structure caused by pregnancy and delivery. METHODS: A total of 141 nulliparous women were examined with three-dimensional transperineal ultrasound (3D-TPU) at the 24th and 34th weeks of gestation, 5th day postpartum, and 1 month postpartum. Puborectalis muscle trauma was diagnosed and the area of levator hiatus (ALH) was measured. RESULTS: One hundred and five normal vaginal deliveries, 19 vacuum/forceps deliveries, and 17 cesarean deliveries were included. In the normal delivery group, the rate of puborectalis muscle trauma was low and showed no significant change between the 24th and 34th weeks of gestation (12.5% vs. 17.2%, p = 0.42). The rate of trauma significantly increased to 70.2% at the 5th day postpartum (p < 0.001). There was no significant difference between the rates at the 5th day postpartum and 1 month postpartum (73.7%, p = 0.60). The same trend was found in the vacuum/forceps group. In the cesarean section group, no significant change was observed throughout pregnancy and postpartum periods. In the normal delivery group, ALH significantly increased between the 24th and 34th week (14.1 ± 2.6 cm2 vs. 14.6 ± 3.4 cm2, p = 0.007). ALH markedly increased to 20.9 ± 4.8 cm2 at the 5th day postpartum (p < 0.001). ALH at 1 month postpartum decreased to 17.0 ± 4.3 cm2 (p < 0.001), but did not return to the value at the 24th week (p < 0.001). CONCLUSIONS: Vaginal childbirth results in enlargement of the levator hiatus. Pelvic floor muscles in pregnant women are affected not only by mechanical damage associated with delivery but also by physiologic changes during pregnancy. The effects of pregnancy and delivery on pelvic floor muscles may persist after delivery.

Guideline for Gynecological Practice in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2020 edition.

Nine years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the 4th Revised Edition was published in 2020. The 2020 Guidelines includes 4 additional clinical questions (CQ), which brings the total to 99 CQ (12 on infectious disease, 29 on oncology and benign tumors, 29 on endocrinology and infertility and 29 on healthcare for women). Currently, a consensus has been reached on the Guidelines, and therefore, the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding Recommendation Level (A, B, C) is indicated.

Successful treatment of severe acute respiratory distress syndrome due to Group A streptococcus induced toxic shock syndrome in the third trimester of pregnancy-effectiveness of venoarterial extracorporeal membrane oxygenation: A case report.

We report a case of Group A streptococcal infection-induced toxic shock syndrome (GAS-TSS) with severe acute respiratory distress syndrome (ARDS), successfully treated with venoarterial extracorporeal membrane oxygenation (V-A ECMO). A 31-year-old woman was transferred due to high fever, continuous uterine contractions and fetal bradycardia at 31 weeks of gestation. She was in a shock status on arrival, and as fetal heart beat disappeared, we canceled the cesarean section and took priority in maternal rescue. At 21 h after the admission, pulseless ventricular tachycardia occurred, and V-A ECMO was introduced after defibrillation, which dramatically improved her respiratory and circulatory conditions. On the 3rd day, GAS was isolated from blood culture. The patient was freed from V-A ECMO on the 5th day and was discharged on the 25th day without permanent impairment. V-A ECMO should be considered as an effective therapeutic option against ARDS and circulation failure in GAS-TSS during pregnancy.

Association of the hypoxia-inducible factor-1α (HIF-1α) gene polymorphisms with prognosis in ovarian clear cell carcinoma.

BACKGROUND: Ovarian clear cell carcinoma (OCCC) is the second most common ovarian cancer after serous carcinoma in Japan. OCCC has a more unfavorable clinical outcome due to a poor response to platinum-based chemotherapy, compared with serous carcinoma. Hypoxia inducible factor-1α (HIF-1α) is a key regulator of cellular response to hypoxia and plays an important role in tumor growth, and HIF-1α gene single-nucleotide polymorphisms (SNPs) adversely affect the outcome in some cancers. Herein, we investigated the association of the HIF-1α gene SPNs with clinical outcome in OCCCs. Eighty-nine patients with OCCC were recruited in whom pathological diagnosis was confirmed with surgically resected specimen. RESULTS: The SNPs of C1772T and G1790A in the HIF-1α gene occurred in 23.6 and 3.3% of the patients, respectively. In the univariate analysis, overall survival was associated with stage and surgical residual tumor but not with the SNPs C1772T, G1790A, C1772T and/or G1790A. In the multivariate survival analysis, a significant association was observed between outcome and FIGO stage and/or surgical residual tumor; however, no association was obtained between HIF-1α gene SNPs and these factors. CONCLUSION: In conclusion, unlike the other cancers in which HIF-1α gene SNPs were demonstrated to be associated with the outcome, OCCC prognosis may not be affected by HIF-1α gene SNPs. Further studies need to be performed to clarify the association of HIF-1α expression with the unfavorable prognosis in OCCCs, in terms of transcriptional/translational activity, nuclear translocation of the protein, and protein degradation.

Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2017 edition.

Six years after the first edition of The Guideline for Gynecological Practice, which was jointly edited by The Japan Society of Obstetrics and Gynecology and The Japan Association of Obstetricians and Gynecologists, the third revised edition was published in 2017. The 2017 Guidelines includes 10 additional clinical questions (CQ), which brings the total to 95 CQ (12 on infectious disease, 28 on oncology and benign tumors, 27 on endocrinology and infertility and 28 on healthcare for women). Currently a consensus has been reached on the Guidelines and therefore the objective of this report is to present the general policies regarding diagnostic and treatment methods used in standard gynecological outpatient care that are considered appropriate. At the end of each answer, the corresponding recommendation level (A, B, C) is indicated.

Weight reduction using a formula diet recovers menstruation in obese patients with an ovulatory disorder.

Aim: To determine the effectiveness of a formula diet in weight reduction and the recovery of menstruation in obese patients with ovulatory disorders. Methods: After the enrollment of 39 obese women with ovulatory disorders, they replaced one or two of their three normal meals with a microdiet (MD) (240 kcal/meal) for 24 weeks. Physical, endocrinological, and biochemical tests were conducted before and at 12 and 24 weeks of the study. Of the 39 women enrolled, 26 were not taking clomiphene. They were divided into three groups according to their body weight outcomes and then analyzed for menstruation recovery. Results: A weight reduction of ≥5% was observed in 31 (81.5%) of the 39 women. There were significant decreases in the body weight and Body Mass Index during the study. Menstruation returned in 18 (69%) of the 26 patients without clomiphene treatment, with the recovery being significantly more prevalent in the groups (totally 81.0%) that exhibited a 5%-10% weight reduction and ≥10% weight reduction, compared to the group with a <5% weight reduction. Conclusion: The use of a formula diet effectively reduced the patients' body weight and led to the recovery of menstruation in these obese patients with ovulatory disorders.

MicroRNA-135b suppresses extravillous trophoblast-derived HTR-8/SVneo cell invasion by directly down regulating CXCL12 under low oxygen conditions.

The expression of numerous microRNAs (miRNAs) in the trophoblasts changes under low oxygen conditions. However, little is known regarding the regulation of the trophoblast invasion by miRNAs under low oxygen conditions. The aim of this study was to identify those miRNAs and their target genes associated with the trophoblast invasion under low oxygen conditions. Culturing the extravillous trophoblast (EVT) cell line, HTR-8/SVneo, at 2% oxygen as compared to 20% oxygen suppressed trophoblast invasion that correlated with increased expression of microRNA-135b (miR-135b) and decreased expression of the its predicted target gene CXCL12. Overexpression of miR-135b suppressed CXCL12 mRNA expression and invasion of HTR-8/SVneo cells. Adding a neutralizing antibody against CXCL12 to the culture medium suppressed HTR-8/SVneo cell invasion. Reporter assays showed that the 3'UTR sequence of CXCL12 was directly targeted by miR-135b. Our results suggest that miR-135b and CXCL12 play important roles in modulating the EVT invasion under low oxygen conditions.

Bladder neck evaluation by perineal ultrasound before and after reconstructive surgery for pelvic organ prolapse.

PURPOSE: To study the correlation between stress urinary incontinence (SUI) and the mobility and funneling of the bladder neck (BN) by observation of pre- and postoperative course by perineal ultrasound (PUS). METHODS: We investigated 123 cases that underwent reconstructive surgery for pelvic organ prolapse (POP). We prospectively checked bladder neck mobility (BNM) during the Valsalva maneuver and funneling of the BN at rest by PUS. We defined the width multiplied by the depth of the funnel-like profile of the BN as the funneling index (FI). We checked BNM, FI, and the presence of SUI just before the operation, and we checked the postoperative course of BNM and SUI. RESULTS: When BNM was ≥10 mm before surgery, the odds ratio for accompanying SUI was 2.68 relative to BNM <10 mm (p = 0.031). When FI was ≥150 before surgery, the odds ratio for accompanying SUI was 4.12 relative to FI <150 (p = 0.004). Although postoperative BNM values were significantly improved immediately after surgery, they gradually increased within 2 years. Among the cases with preoperative SUI, the recurrence rate was significantly higher in the patients whose FI was <150 (p = 0.019). CONCLUSIONS: Our results yielded by PUS suggested that larger BNM and FI values were the causative factors of SUI. PUS may be beneficial for selecting a suitable surgical procedure for POP, and it may also be helpful for assessing surgical efficacy.

Magnetic resonance imaging findings of vulvar epithelioid sarcoma.

We describe here a case of vulvar epithelioid sarcoma. Epithelioid sarcoma is a malignant appendicular skin tumor that is rarely of vulvar origin. Magnetic resonance imaging (MRI) revealed a solid mass with an ulcer-like lesion and multilobulated contour. To our knowledge, this is the first case of vulvar epithelioid sarcoma described in the MRI literature.

LPS-induced transient testicular dysfunction accompanied by apoptosis of testicular germ cells in mice.

The aim of this study was to clarify effects of inflammation on spermatogenesis in LPS-administered mice. ICR mice were treated by intraperitoneal injection for 7 days with either physiological saline (control) or 0.1 mg lipopolysaccharide (LPS)/kg body weight/day. Control mice were killed at 24 h after the last injection and the LPS-treated group after 24 h or 1, 3, or 5 weeks. Sperm concentration and motility in the cauda epididymis were examined as well as immunohistochemical localization of Fas and FasL and germ cell apoptosis. Sperm concentration and motility markedly fluctuated in LPS-treated mice. Increase of apoptotic cells was common in all post-LPS treatment groups, with a peak at 24 h after LPS injection. In contrast to the lack of Fas immunoreactivity in control testes, LPS-treated groups demonstrated Fas in many germ cells, especially in spermatocytes and spermatids. Immunoreactivity for FasL, on the other hand, was positive for some Sertoli cells, Leydig cells, and germ cells in both control and LPS-treated groups at all time points. The results suggest that the Fas/FasL system mediates apoptosis of germ cells in LPS-treated mice testes. LPS-administered mice thus provide a good experimental model for the study of transient disruption of spermatogenesis.

Bcl-x is not required for maintenance of follicles and corpus luteum in the postnatal mouse ovary.

It has been proposed that Bcl-x is a key survival factor in many cell types, and that the bcl-x gene is activated by the transcription factor Stat5 through cytokine signals. In support of this, it has been demonstrated that the survival of mouse primordial germ cells during embryogenesis depends on the presence of Bcl-x. We have now investigated whether, in the mouse, Bcl-x is required for the postnatal maintenance of follicles and luteal cells, and whether Stat5 activates the bcl-x gene. The bcl-x gene was deleted in these cells within the mouse using Cre-loxP recombination. Loss of the bcl-x gene did not affect the numbers of primordial, primary, and antral follicles. Furthermore, expression of the bcl-x gene in the ovary was independent of Stat5 and its activating hormone, prolactin. To determine whether the prolactin receptor (PrlR), Stat5, and Bcl-x were required for establishment and maintenance of the corpus luteum, we induced pseudopregnancies in the respective gene-deletion mice. Whereas luteal cells underwent apoptosis in the absence of the PrlR, no changes were observed in the absence of Stat5 or Bcl-x.