Impact of surgical adhesion barrier on significant adhesion during a repeat cesarean section

　Background: Post-cesarean adhesions are associated with delayed infant delivery and infertility. In this retrospective study, we analyzed the effects of hyaluronic acid- carboxymethylcellulose (HA/CMC) membranes on postoperative adhesion during cesarean section.　Methods: Sixty-seven patients were divided into the surgical adhesion barrier used (n = 28) and not-used group (n = 39). We compared the severity of adhesion at the repeat cesarean section, as well the following variables: operation and incision delivery time, blood loss, and postoperative infection between both groups. The severity of adhesion was analyzed using the Zühike’s adhesion score between the abdominal wall and uterine corpus, and the Steinleitner’s uterine adhesion score.　Results: We found that the Zühike’s adhesion score between the abdominal wall and corpus of the uterus in the surgical adhesion barrier used group was significantly lower than that of the not-used group (0.46 ± 0.2 and 1.0 ± 0.2, respectively) (p = 0.04). The Steinleitner’s uterine adhesion score of the surgical adhesion barrier used group was lower than that of the not-used group (0.5 ± 0.3 and 1.3 ± 0.3, respectively), but not significantly (p = 0.07).　Discussion: We concluded that the surgical adhesion barrier was effective in preventing postoperative adhesion formation during cesarean sections. However, further investigations are necessary to reveal the usefulness of the surgical adhesion barrier during cesarean section, including its cost-effectiveness

腹腔鏡検査にて確定診断に至った結核性腹膜炎の一例

　症例は63歳女性．元医療従事者であった．１ヵ月続く腹痛と38度の発熱で近医を受診し，腹水貯留を認め，腹水検査でヒアルロン酸とCA125が高値であったことから癌性腹膜炎を疑われ当院内科に紹介された．画像検査より癌性腹膜炎を疑われたが，原発は同定できなかった．細胞診はclassII であったが，卵巣癌，腹膜癌，悪性中脾腫を疑われたことから，腹腔鏡検査目的に当科紹介となった．腹腔鏡検査で黄白色粒状の病変を認め，病理組織検査にて類上皮細胞性肉芽腫を認め，結核等の感染症が疑われた．病歴聴取にて３年前の職務中に結核排菌患者に濃厚接触歴あり，腹腔鏡再検査にて，塗抹，培養，PCR 陰性であったが，腹水中ADA 高値より結核と診断し結核専門病院に転院した．抗結核薬開始され速やかに症状は軽快した．結核性腹膜炎は非常に稀な疾患であるが，腹腔鏡検査で診断に至った症例を経験した．原因不明腹水を認めた場合，癌性腹膜炎のみならず感染性腹膜炎の可能性も念頭に置き早期から同時に精査する必要がある．　A 63-year-old woman, who was a former healthcare professional, visited a nearby clinic for headache and a fever of 38℃ that had lasted for a month. Ascites was observed, and ascitic fluid examination showed high hyaluronan and CA125 levels, suggesting cancerous peritonitis. She was referred to the internal medicine department at our institution. Although the primary site was not identified, imaging findings suggested cancerous peritonitis. Cytology showed class II features, with the possibility of ovarian cancer, peritoneal cancer, or malignant mesothelioma. She was referred to our department for laparoscopic examination, which showed epithelioid cell granulomas, suggesting an infectious disease, which could include tuberculosis. History taking revealed close contact with a tuberculosis-shedding patient at work 3 year ago. Although the smear, culture, and polymerase chain reaction tests were negative, on laparoscopic reexamination, tuberculosis was diagnosed because of elevated adenosine deaminase in the ascitic fluid. She was transferred to a tuberculosis specialty hospital;antituberculosis therapy was started, and the symptoms quickly resolved. We experienced a very rare case of tuberculous peritonitis, diagnosed laparoscopically. Ascites from an unknown cause requires close examination for not only cancerous peritonitis but also infectious peritonitis

Cyclin dependent kinase inhibitorによる神経前駆細胞の分化誘導と脳形成

大脳皮質は知覚,認知,思考等の高次機能を担う中枢である.哺乳類では大脳皮質は6層構造をなし,それぞれの層では機能的,形態的に類似した細胞集団が異なる領域からの投射をやり取りしている.神経細胞およびグリア細胞は,胎生期から生後にかけて神経前駆細胞(Neural progenitor cell,NPC)から分裂し産生される.NPCは時期に応じて神経細胞,続いてグリア細胞へ分化し,最終的な脳の構造が完成する.NPCから分化する細胞運命の決定には,細胞分裂を中止して分化を始める機構が必要であり,その中でもCyclin dependent kinase inhibitors(CKIs)の働きが注目されている.今回我々はこのCKIsのひとつであるp18遺伝子を用いて胎児マウス脳の発生に与える影響を解析した.方法としては胎生13～17日目(E13-17)のマウス胎児脳にp18遺伝子を子宮内エレクトロポレーション法によって強制発現させ,その後に脳組織内での分布を観察した.またCre-LoxP を用いた蛍光蛋白発現システムで個々の細胞形態の立体再構築を行った.その結果,p18遺伝子発現群はコントロール群に比べて多く脳室面側に留まり,特にE14, 15において顕著に認められた.更に遺伝子導入した細胞において分化後の形態を観察したところ,生後脳においてp18遺伝子発現群ではアストロサイトの形態をした細胞が増えており,免疫組織学的染色からもこれらの細胞がアストロサイトであることが示唆された.この細胞はE13～E17いずれの時期においても増加していたが,特にE14,15で顕著に認めたことから,この時期にニューロンの分化からアストロサイトの分化に切り替わる何らかのメカニズムが存在していると考えられた.今回の研究によってNPCがニューロンへの分化からアストロサイトへの分化に切り替わるメカニズムにCKIsが関与している可能性が示唆された.アストロサイトはグルタミントランスポータの発現により,二次的脳損傷から神経細胞を保護しており,その発生が解明されることで低酸素性虚血性脳症の治療への応用も期待される.The cerebral cortex plays a central role in high-level functions such as thinking, perception, and cognition. In mammals, the cerebral cortex has a six-layered structure, and each layer contains cells with similar functions and shapes that exchange signals from different regions of the brain. Neurons and glial cells are produced by differentiation from neural progenitor cells(NPC)from the embryonic stage up to the postnatal stage. NPCs are differentiated into neurons at the embryonic stage, and switch into glial cells at birth, before the structure of the brain is mature. Some molecules have been proposed to determine the cell fate of NPCs by stopping cell division and initiating differentiation. Cyclindependent kinase inhibitors(CKIs)are considered to be important molecular factors in this process. Here we used a CKI, the p18 gene, and analyzed its effect on the formation of the fetal mouse brain. For this purpose, we expressed the p18 gene in the mouse fetal brain at embryonic day 13 to day 17(E13-17), and observed the distribution of the electroporated cells in the cortical tissue. Furthermore, we performed three-dimensional reconstruction of the individual cellular morphology by using the Cre-LoxP fluorescent protein expression system. As a result, the p18-gene expressing cells remained in the ventricular zone more than the control cells. The difference was particularly remarkable at E14 and E15. Importantly, we observed a differentiated cell shape in electroporated cells, and found that the proportion of astrocyte-like cells was greatly increased in the p18 gene-expressing group compared to the control group. We confirmed that these cells were indeed astrocytes with immunohistochemical staining. The number of such astrocyte-like cells increased at any time of electroporation from E13 to E17, especially at E14 and E15. Therefore, we propose that there might be some mechanisms that control the switch from neurons to astrocytes at this stage of development. In conclusion, our study suggests that CKIs are involved in the differentiation program of NPCs from neurons to astrocytes. Astrocytes are known to protect neurons from secondary brain damage by the expression of glutamine transporter. Therefore, elucidating the mechanism of their generation is expected to have applications for the treatment of hypoxic-ischemic encephalopathy in the future

妊娠中期の妊婦に発症し，体外式腹部超音波検査にて術前診断しえた虫垂憩室炎の一例

虫垂憩室炎は比較的稀な疾患であり，急性虫垂炎と比べ，穿孔率が高いがその術前診断は難しい．体外式腹部超音波検査で術前に診断した虫垂憩室炎の1症例を経験したので，文献的考察を加えて報告する．症例は24歳，妊娠25週５日の女性．腹痛を主訴に近医を受診したところ，急性虫垂炎の疑いで当院へ紹介受診となった．体外式腹部超音波検査で，虫垂憩室炎と診断し，緊急手術となった．切除標本の病理学的検査により，虫垂憩室炎と確定診断された．Preoperative diagnosis of appendiceal diverticulitis is considered difficult. Differentiation between acute appendicitis and appendiceal diverticulitis is clinically important because the latter condition has a higher risk of perforation. We report a case of a 24-year-old pregnant (25 weeks and 5 days of gestation) woman who complained of right lower quadrant pain. After visiting a primary care doctor, she was referred to our hospital with suspected acute appendicitis. Ultrasound showed that the appendix was swollen and there were several low echoic lesions in the vicinity of the point of the appendix. Blood flow was shaped in an arc around the low echoic lesion as shown by Doppler color flow imaging. We observed thickness and hyperechoic change, which was affected by inflammation in the mesoappendix. She underwent appendectomy and a pathological examination of the resected specimen confirmed the diagnosis of appendiceal diverticulitis

Postoperative nausea and vomiting in benign gynecological laparoscopic surgery when acetaminophen is combined with non-opioid analgesic management

　Non-opioid analgesic management using intravenous acetaminophen has been reported to reduce pain and postoperative nausea and vomiting (PONV). This study aimed to assess the incidence rate and risk factors for PONV following benign gynecological laparoscopic surgery with non-opioid analgesic management, when using intravenous acetaminophen to achieve appropriate perioperative management. We conducted a retrospective observational study comprising 53 patients who underwent five types of laparoscopic surgical procedures for benign diseases. The patients were administered a single dose of intravenous acetaminophen at the conclusion of the operation, after which pain relief was induced with non-steroidal anti-inflammatory drugs and pentazocine. We analyzed patient characteristics, surgical outcomes, and numbers of analgesics and antiemetics administered postoperatively. Onset of PONV developed by postoperative day one. The incidence rate of PONV in patients who underwent surgery that included total hysterectomy was 94%, which was significantly higher than in those who underwent other procedures ( p = 0.020). From the perspective of PONV, current postoperative pain management for laparoscopic surgery, including total hysterectomy, needs to be modified