Laparoscopic Myomectomy Followed by Minilaparotomy for Management of a Large Submucous Fibroid

Background: We describe a patient with a single large type II submucous fibroid distorting and occupying the entire endometrial cavity, which was managed successfully with an approach less invasive than laparotomy. Case: The patient was a 36-year-old woman who presented with primary infertility of 2 years duration. Her associated complaints were menorrhagia and known uterine fibroids. She had undergone hysteroscopic myomectomy in the past without any improvement. An hysterosalpingogram revealed that the uterine cavity was occupied by a single large submucosal fibroid. Transvaginal ultrasound and saline infusion hysterosonogram showed a large anterior type II submucous, intramural, subserous fibroid. Diagnostic hysteroscopy and laparoscopy revealed a type II submucous fibroid occupying the entire anterior wall of the uterus. Laparoscopic myomectomy was performed and a fibroid measuring 8?cm was dissected. During the process, the endometrial cavity was entered and a minilaparotomy via a 5-cm transverse skin incision was performed to repair the endometrial cavity and overlying myometrium adequately and to remove the myoma. Results: Her postoperative course was uneventful. Six weeks later, saline infusion hysterosonogram revealed a uniform endometrial cavity with no filling defects or synechiae. Conclusions: Laparoscopic myomectomy with minilaparotomy is a safe, cost-effective, and less invasive approach for the treatment of patients with large type II submucous fibroids who want to preserve their reproductive potential. (J GYNECOL SURG 29:161)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140091/1/gyn.2012.0027.pd

Management Dilemma of an Infertile Patient with More Than 20 Submucous Fibroids

Background: Submucous fibroids can lead to menorrhgia, infertility, recurrent pregnancy loss, and obstetric complications. The management of multiple submucous fibroids in patients who would like to preserve their reproductive function can be a challenge. The aim of this report is to discuss the management dilemma of a patient who presented with multiple (more than 20) submucous fibroids. Case: The patient was a 33-year-old Caucasian woman who had an initial complaint of menometrorrhagia and secondary infertility, which led to a diagnostic hysteroscopy. Multiple submucosal fibroids were noted; no other etiology for infertility was identified. She subsequently underwent hysteroscopic resection of several fibroids. Postoperative hyterosalpingogram demonstrated intrauterine scarring, unilateral tubal blockage, and several remaining fibroids. She did, however, conceive with intrauterine insemination. Unfortunately, this pregnancy ended in an early spontaneous abortion of twins. After being counseled on her options, including the possibility of needing a surrogate uterus, she elected to have an abdominal resection of the remaining fibroids. During this procedure, several steps were taken to restore the uterine cavity to a normal shape. After allowing her uterus to heal, she achieved pregnancy through in vitro fertilization. At 29 weeks of gestation, she had preterm premature rupture of membranes and, subsequently, had a cesarean section at 34 weeks of gestation. She had a viable 6 pound 1 ounce baby boy. At the time of her cesarean section, only one submucosal fibroid was identified. Conclusion: We present a unique case of multiple sub-mucous fibroids that failed hysteroscopic management and were subsequently treated successfully with hysterotomy, myomectomy, and uterine reconstructive surgery. Based on our experience with this case, we recommend hysterotomy and myomectomy for management of multiple sub-mucous fibroids from the outset. (J GYNECOL SURG 31:274)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140098/1/gyn.2014.0123.pd

COVID-19 Public Transportation Air Circulation and Virus Mitigation Study

COVID-19 may have forever changed our world. Given the limited space and air circulation, potential infections on public transportation could be concerningly high. Accordingly, this study has two objectives: (1) to understand air circulation patterns inside the cabins of buses; and (2) to test the impact of different technologies in mitigating viruses from the air and on surfaces inside bus cabins. For the first objective, different devices, metrics and experiments (including colored smoke; videotaping; anemometers; pressure differentials; particle counts; and 3D numerical simulation models) were utilized and implemented to understand and quantify air circulation inside different buses, with different characteristics, and under different operating conditions (e.g. with windows open and shut). For the second objective, three different live prokaryotic viruses were utilized: Phi6, MS2 and T7. Various technologies (including positive pressure environment inside the cabin, HEPA filters with different MERV ratings, concentrated UV exposure with charged carbon filters in the HVAC systems, center point photocatalytic oxidation technology, ionization, and surface antiviral agents) were tested to evaluate the potential of mitigating COVID-19 infections via air and surfaces in public transportation. The effectiveness of these technologies on the three live viruses was tested in both the lab and in buses in the field. The results of the first objective experiments indicated the efficiency of HVAC system designs, where the speed of air spread was consistently much faster than the speed of air clearing. Hence, indicating the need for additional virus mitigation from the cabin. Results of the second objective experiments indicated that photocatalytic oxidation inserts and UVC lights were the most efficient in mitigating viruses from the air. On the other hand, positive pressure mitigated all viruses from surfaces; however, copper foil tape and fabrics with a high percentage of copper mitigated only the Phi6 virus from surfaces. High-temperature heating was also found to be highly effective in mitigating the different viruses from the vehicle cabin. Finally, limited exploratory experiments to test possible toxic by-products of photocatalytic oxidation and UVC lights inside the bus cabin did not detect any increase in levels of formaldehyde, ozone, or volatile organic compounds. Implementation of these findings in transit buses, in addition to the use of personal protective equipment, could be significantly valuable for protection of passengers and drivers on public transportation modes, possibly against all forms of air-borne viruses

Myometrial Abscess: A Complication of Myomectomy of a Large Lower-Uterine Segment Myoma

Background: This article describes a patient with a history of two early miscarriages. She presented with menorrhagia and a recurrence of multiple fibroids. Laparotomy and myomectomy were performed and were complicated by a myometrial abscess. The diagnosis and management of such a rare complication are described. Case: A 39-year-old African American female (gravida 3, para 1) presented with a history of two early miscarriages, menorrhagia, and a recurrence of multiple fibroids. An ultrasound (US) scan revealed an enlarged uterus with at least six uterine fibroids. Laparotomy and myomectomy were performed. Four weeks later, this patient presented with complaints of pelvic pain, nausea, vomiting, constipation, and a fever of 1 day's duration. A US scan revealed a slightly enlarged uterus caused by a possible infected hematoma. The patient was admitted to the hospital and she was started on intravenous antibiotics after a blood culture was obtained. A computed tomography (CT) scan of her abdomen and pelvis confirmed the diagnosis of a myometrial abscess. This patient underwent CT scan?guided placement of a ?pigtail? catheter in the myometrial abscess for continuous drainage. The result of the culture of the pus obtained from the abscess revealed the presence of multiple bacteria. The pigtail catheter was removed once there was no drainage 2 weeks after its initial insertion. Results: Two months after her discharge, a transvaginal US scan revealed that this patient's condition was essentially normal. Conclusions: This case report describes how a minimally invasive technique was used to manage a myometrial abscess, which is a complication of myomectomy. This report also illustrates the value of transvaginal US scanning for diagnosing such a pathology, and the roles US plays during management and follow-up. (J GYNECOL SURG 30:240)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140095/1/gyn.2013.0130.pd

How long do patients with chronic disease expect to live? A systematic review of the literature

OBJECTIVE: To systematically identify and summarise the literature on perceived life expectancy among individuals with non-cancer chronic disease. SETTING: Published and grey literature up to and including September 2016 where adults with non-cancer chronic disease were asked to estimate their own life expectancy. PARTICIPANTS: From 6837 screened titles, 9 articles were identified that met prespecified criteria for inclusion. Studies came from the UK, Netherlands and USA. A total of 729 participants were included (heart failure (HF) 573; chronic obstructive pulmonary disease (COPD) 89; end-stage renal failure 62; chronic kidney disease (CKD) 5). No papers reporting on other lung diseases, neurodegenerative disease or cirrhosis were found. PRIMARY AND SECONDARY OUTCOME MEASURES: All measures of self-estimated life expectancy were accepted. Self-estimated life expectancy was compared, where available, with observed survival, physician-estimated life expectancy and model-estimated life expectancy. Meta-analysis was not conducted due to the heterogeneity of the patient groups and study methodologies. RESULTS: Among patients with HF, median self-estimated life expectancy was 40% longer than predicted by a validated model. Outpatients receiving haemodialysis were more optimistic about prognosis than their nephrologists and overestimated their chances of surviving 5 years. Patients with HF and COPD were approximately three times more likely to die in the next year than they predicted. Data available for patients with CKD were of insufficient quality to draw conclusions. CONCLUSIONS: Individuals with chronic disease may have unrealistically optimistic expectations of their prognosis. More research is needed to understand how perceived life expectancy affects behaviour. Meanwhile, clinicians should attempt to identify each patient's prognostic preferences and provide information in a way that they can understand and use to inform their decisions. TRIAL REGISTRATION NUMBER: CRD42015020732

Modular Neural Network Approaches for Surgical Image Recognition

Deep learning-based applications have seen a lot of success in recent years. Text, audio, image, and video have all been explored with great success using deep learning approaches. The use of convolutional neural networks (CNN) in computer vision, in particular, has yielded reliable results. In order to achieve these results, a large amount of data is required. However, the dataset cannot always be accessible. Moreover, annotating data can be difficult and time-consuming. Self-training is a semi-supervised approach that managed to alleviate this problem and achieve state-of-the-art performances. Theoretical analysis even proved that it may result in a better generalization than a normal classifier. Another problem neural networks can face is the increasing complexity of modern problems, requiring a high computational and storage cost. One way to mitigate this issue, a strategy that has been inspired by human cognition known as modular learning, can be employed. The principle of the approach is to decompose a complex problem into simpler sub-tasks. This approach has several advantages, including faster learning, better generalization, and enables interpretability. In the first part of this paper, we introduce and evaluate different architectures of modular learning for Dorsal Capsulo-Scapholunate Septum (DCSS) instability classification. Our experiments have shown that modular learning improves performances compared to non-modular systems. Moreover, we found that weighted modular, that is to weight the output using the probabilities from the gating module, achieved an almost perfect classification. In the second part, we present our approach for data labeling and segmentation with self-training applied on shoulder arthroscopy images

Pregnancy Outcomes After Endometrioma Excision in Patients Undergoing In Vitro Fertilization and Embryo Transfer: A Historical Cohort Study

Objective: The objective of the study was to examine the effect of endometrioma excision on pregnancy outcomes in women with advanced-stage endometriosis who underwent in vitro fertilization and embryo transfer (IVF-ET). Design: This is a historical cohort study. Materials and Methods: We compared the pregnancy outcomes of 141 women undergoing IVF-ET. The study group consisted of 25 patients who had stage III/IV endometriosis and endometrioma excision (group 1). The control groups included 40 patients who had stage III/IV endometriosis, but no endometrioma and who underwent ovariolysis (group 2) and 76 patients with tubal factors infertility who underwent tubal surgery (group 3). After surgery up to two IVF-ET cycles in each group were analyzed. Results: Our study showed that the mean total dose of gonadotropin administered in IVF-ET cycle I was higher in group 1 compared with groups 2 and 3 (p=0.03). Otherwise, there was no significant difference in the ovarian responses among the three groups. There was a statistically significant increase in clinical pregnancy rate per cycle in the endometrioma group (69.7%) versus the ovariolysis group (48.1%) and tubal factor group (48.0%). However, there was no significant difference in delivery rate per cycle among the three groups. There was a statistically significant higher miscarriage rate in the endometrioma group (39.1%) compared with the ovariolysis group (11.5%) and tubal factor group (14.3%). Conclusion: In conclusion, our study suggests that endometrioma excision surgery does not compromise the overall ovarian reserve or pregnancy outcomes after IVF-ET. (J GYNECOL SURG 31:214)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140100/1/gyn.2015.0013.pd

Effects of sun-drying and exogenous enzymes on nutrients intake, digestibility and nitrogen utilization in sheep fed Atriplex halimus foliages

This study was conducted to assess effects of sun-drying and/or addition of an exogenous enzyme (ENZ) preparation on intake, digestibility of nutrients and recovery values of secondary metabolites (SM) in the gastrointestinal tract of sheep fed Atriplex halimus (AH) foliages. A randomized block design for 28 d was used for four experimental treatments based on either fresh (AH-F) or sun-dried (AH-S) A. halimus foliages in the absence (−ENZ) or presence (+ENZ) of 10 g/sheep/d of the exogenous of ZADO® enzyme preparation. Three adult sheep weighing 51 ± 2.7 kg were fed for each experimental treatment. The ENZ was added daily with a small amount of concentrate to help balance the dietary metabolizable energy concentration. Nutrient intake and digestibility, N balance and recovery of SM (i.e., total phenolics (TP), saponins (SP), alkaloids (AK), aqueous fraction (AF)) in the gastrointestinal tract were determined. Levels of most nutrients did not differ between AH-F and AH-S foliages, but the AH-S contained less than half of the SM in AH-F. Drying of A. halimus and ENZ addition increased (P=0.001) intake as well as OM and NDFom digestibility (P=0.02). Feed intake and digestibility were higher (P=0.01) in AH-S with ENZ addition. Intake of N by sheep fed the treatment diets depended on DM intake as the dietary concentration of N in the diets was similar. Thus AH-S sheep supplemented with ENZ had higher (P=0.001) N intake. Digestibility of N was similar to DM and OM digestibility, and was higher (P=0.03) in AH-S sheep supplemented with ENZ. Drying and ENZ addition to the diet increased (P=0.004) recovery of all SM. The fate of these compounds in the rumen needs to be evaluated considering that SM have been implicated in fiber and protein degradation in the rumen. The study showed that there are beneficial impacts of sun-drying and/or dietary exogenous enzyme addition for sheep fed A. halimus