Endometriosis

The induction of CD11b(+)Gr-1(+) myeloid-derived suppressor cells (MDSCs) is an important immune-evading mechanism used by tumors. However, the exact nature and function of MDSCs remain elusive, especially because they constitute a heterogeneous population that has not yet been clearly defined. Here, we identified 2 distinct MDSC subfractions with clear morphologic, molecular, and functional differences. These fractions consisted of either mononuclear cells (MO-MDSCs), resembling inflammatory monocytes, or low-density polymorphonuclear cells (PMN-MDSCs), akin to immature neutrophils. Interestingly, both MO-MDSCs and PMN-MDSCs suppressed antigen-specific T-cell responses, albeit using distinct effector molecules and signaling pathways. Blocking IFN-gamma or disrupting STAT1 partially impaired suppression by MO-MDSCs, for which nitric oxide (NO) was one of the mediators. In contrast, while IFN-gamma was strictly required for the suppressor function of PMN-MDSCs, this did not rely on STAT1 signaling or NO production. Finally, MO-MDSCs were shown to be potential precursors of highly antiproliferative NO-producing mature macrophages. However, distinct tumors differentially regulated this inherent MO-MDSC differentiation program, indicating that this phenomenon was tumor driven. Overall, our data refine tumor-induced MDSC functions by uncovering mechanistically distinct MDSC subpopulations, potentially relevant for MDSC-targeted therapies.

Identification of discrete tumor-induced myeloid-derived suppressor cell subpopulations with distinct T-CELL suppressive activity

OBJECTIVE
We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006.


STUDY DESIGN
This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined.


RESULTS
Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20.


CONCLUSION
Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

Iconographies supplémentaires de l'article : Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery

Surgical Treatment of Female Stress Urinary Incontinence: AUA/SUFU Guideline

BACKGROUND
Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse.


OBJECTIVES
To determine the effects of surgery in the management of pelvic organ prolapse.


SEARCH STRATEGY
We searched the Cochrane Incontinence Group trials register (8 June 2004) and reference lists of relevant articles. We also contacted researchers in the field.


SELECTION CRITERIA
Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.


DATA COLLECTION AND ANALYSIS
Trials were assessed and data extracted independently by at least two reviewers. Four investigators were contacted for additional information with two responding.


MAIN RESULTS
Fourteen randomised controlled trials were identified evaluating 1004 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were to evaluate other clinical outcomes and adverse events. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by Vicryl mesh overlay (RR 1.39, 95% CI 1.02 to 1.90) but data on morbidity and other clinical outcomes were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh overlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new symptoms after surgery. However, more women with occult stress urinary incontinence developed postoperative stress urinary incontinence after endopelvic fascia plication alone than after endopelvic fascia plication and tension-free vaginal tape (RR 5.5, 95% CI 1.36 to 22.32).


REVIEWERS' CONCLUSIONS
Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of a polyglactin mesh overlay at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. Adequately powered randomised controlled clinical trials are urgently needed.

Surgical Management of Pelvic Organ Prolapse in Women: a Meta-Analysis of Randomised Controlled Trials

Risk factors for mesh erosion after vaginal sling procedures for urinary incontinence.

The aim of this study was to assess the effects of home-based Kegel exercises in women with stress and mixed urinary incontinence. A total of 90 women with urodynamically proven urinary stress (SUI) and mixed (MUI) incontinence awaiting anti-incontinence surgery were recruited in the urogynaecology clinic of Ankara Zekai Tahir Burak Women's Health Research and Education Hospital. Of these, 18 women were excluded due to low compliance and the remaining 72 were divided into two groups according to urodynamic diagnosis (SUI group, n = 38; MUI group, n = 34). Age, BMI, menopausal status and medical history of the women were recorded. The women took Kegel exercise, consisting of 10 sets of contractions/day; each set included 10 repetitions, for at least 8 weeks. To evaluate the pelvic floor muscle strength, the modified Oxford grading system was used before and after Kegel exercising. The Incontinence Impact Questionnaire (IIQ-7); Urogenital Distress Inventory (UDI-6) and the Patient Global Impression of Improvement (PGI-I) questions were compared before and after 8 weeks of Kegel exercising. The age, BMI, gravidity, menopausal status, macrosomic fetus history, hypertension and asthma were similar between the groups. There were statistically significant lower scores in both IIQ-7 and UDI-6 before and after Kegel exercises within each group (p < 0.001). The mean change of the IIQ-7 and UDI-6 score was statistically significantly higher in the SUI group than in the MUI group (p = 0.023 and p = 0.003, respectively). Results of the Oxford scale were also statistically significantly higher after Kegel exercises within each group (p = < 0.001). In total, 68.4% of the women in the SUI group and 41.2% of the women in the MUI group reported improvements which were statistically significant (p = 0.02). We conclude that home-based Kegel exercises, with no supervision, have been found effective in women with SUI and MUI. The improvement was more prominent in women with SUI.

Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence

A prospective randomized trial of postoperative pain following different insufflation pressures during gynecologic laparoscopy.

Objective
To assess the obstetrics risk factors for postpartum urinary retention after vaginal delivery.

Postpartum urinary retention after vaginal delivery: Assessment of risk factors in a case-control study.

Background We aimed to determine if preprocedural anxiety levels had a significant association with procedure-related pain in women undergoing office hysteroscopy (OH) and also to assess the effect of various clinical factors on pain perception in these women. Methods There were 148 women undergoing OH enrolled in this observational study. Before examination, patients were asked to complete two forms, the STAI-T (State–Trait Anxiety Inventory, Trait) and STAI-S (State-Trait Anxiety Inventory, State) anxiety scales, to evaluate their usual anxiety state and state of anxiety during the examination. Patients were asked to quantify on a visual analog scale the pain felt during and 60 minutes after the procedure. Associations between STAI and visual analog scale scores were assessed using correlation analysis. The effects of various contributing factors on pain perception were investigated with linear regression analysis. A p value Results The preprocedural mean trait and state anxiety scores were 38.4 ± 9.2 and 44.8 ± 10.0, respectively, and the mean patient age was 43.6 ± 3.3 years. During OH, there were significant positive correlations between in-hospital waiting time, procedure time, preprocedural trait or state anxiety scores, and pain. Sixty minutes after OH, significant positive correlations between in-hospital waiting time, procedure time, preprocedural state or trait anxiety scores, and pain were observed. There was also a significant negative correlation between parity and procedure-related pain 60 minutes after procedure. OH-related pain scores during the procedure were significantly affected by in-hospital waiting time ( p p  = 0.001), and trait anxiety level ( p  = 0.01). However, 60 minutes after the procedure, pain was affected by patient parity ( p  = 0.02), procedure time ( p  = 0.002), and preprocedural state anxiety level ( p Conclusion The pain that study participants felt during and soon after OH was negatively affected by preprocedural anxiety levels. Some factors, such as reducing the waiting time before the procedure, might be useful in reducing anxiety levels.

Hasan Onur Topçu

Papers

Risk factors for mesh erosion after vaginal sling procedures for urinary incontinence.

Effect of home-based Kegel exercises on quality of life in women with stress and mixed urinary incontinence

A prospective randomized trial of postoperative pain following different insufflation pressures during gynecologic laparoscopy.

Postpartum urinary retention after vaginal delivery: Assessment of risk factors in a case-control study.

Impact of preprocedural anxiety levels on pain perception in patients undergoing office hysteroscopy