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Inflammation plays an important role in peripheral artery disease (PAD), contributing to the onset and progression of atherosclerosis, as well as to the rupture of atherosclerotic plaques. Studies have revealed that due to their inflammatory nature, leucocytes play an important role in the development of atherosclerosis. A retrospective study was conducted involving 203 patients with PAD admitted to Targu Mures Emergency County Hospital for revascularization surgery between January 2017 and June 2019 (of which 47 were treated by endovascular intervention, and 156 underwent classical surgical intervention). Among all patients included in the study, 47 patients required amputation following the revascularization intervention. The results indicated that though the mean patient age in the non-amputation group was higher than that in the amputation group, that the difference was not significant. With regard to sex distribution, 72% of the patients from the amputation group were male, while from the non-amputation group, 74% were male. The neutrophil-to-lymphocyte ratio (NLR) cut-off value for the prediction of amputation in PAD was 3.485 (sensitivity, 60.42%; specificity 72.44%), whereas the platelet-to-lymphocyte ratio (PLR) value was 152, (sensitivity, 54.17%; specificity, 71.79%), and was 2.55 for the lymphocyte-to-monocyte ration (LMR; sensitivity, 56.25%; specificity, 66.88%). The study concluded that in patients with PAD, the NLR and PLR were increased, while the LMR was decreased, which was also associated with a higher rate of amputation after revascularization, despite the lack of correlation between these factors, Fontaine classification and the number of damaged vessels. Therefore, pre-operative alterations in NLR, PLR and LMR may predict the need for amputation in patients with PAD, or those who underwent a revascularization intervention.

Objective: To compare differences in the postoperative pregnancy rate in women seeking to conceive and presenting with endometriomas larger than 3 cm in diameter, which were managed by ablation using plasma energy, cystectomy, or simple drainage. Methods: A retrospective three-arm comparative study based on prospective collection of data evaluating 363 patients, undergoing endometrioma cystectomy, ablation using plasma energy, or simple drainage. Results: In this series, 204 (56.2%) patients underwent endometrioma ablation using plasma energy, 121 (33.3%) received cystectomy, and 38 (10.5%) had a simple drainage. Postoperative follow up was 50 ± 26 months. Overall postoperative pregnancy rate was 60.3%. The probability of being pregnant after cystectomy, ablation, and drainage was respectively 27%, 32%, and 16% at 12 months, with a statistically significant difference between pregnancy rates among the three arms (P = 0.015). Simple drainage was associated with a probability of conception over 50% after 2 years, mainly based on postoperative assisted reproductive technology. Conclusions: We reveal good postoperative pregnancy rate after ablation using plasma energy or cystectomy for endometriomas. Surgical management should be carefully considered in women with endometriomas and pregnancy intention, because the postoperative pregnancy rate may be compared with that observed after first-line assisted reproductive technology management.

Congenital heart disease(CHD) is the most frequent malformative pathology seen in newborns, with an incidence of 10/1000 births, and is considered a major cause of neonatal morbidity and mortality. About one third of congenital heart disease cases are of genetic origin, particular copy number variations being described as possible nonsyndromic and syndromic congenital heart disease causes. Here, we set out to find whether the MLPA technique could be used as a first-tier screening assay in newborns with apparently nonsyndromic CHDs, and thus to genetically confirm the CHD diagnosis. The study cohort included 60 newborns diagnosed with apparently nonsyndromic congenital heart disease, recruited for a period of 18 months. MLPA analysis was performed using the SALSA MLPA P311 and P250 kits. 10 newborns (16.67%) showed known genetically relevant copy number variations, namely three patients with 22q11.21 deletion, that were diagnosed with DiGeorge syndrome, and seven patients with a probable single exon 8p23.1 duplication that will be subjected to further molecular testing, in order to correctly assess their diagnosis. We can conclude that the screening of patients with apparently nonsyndromic congenital heart disease may lead to their early and correct diagnosis, and thus them benefitting from the detection of clinically relevant copy number variations using the MLPA technique.

A previous article sought to signpost papers that were considered helpful when starting on the journey of practicing evidence-based medicine (EBM).1 The lead author was invited to run a workshop at the Eighth Conference of the International Society for Evidence-Based Health Care run in collaboration with the Gruppo Italiano per la Medicina Basata sulle Evidenze from 6 November to 9 November 2019. The aim of the workshop was to challenge a group of teachers and educators to consider useful papers for the teaching of EBM/evidence-based healthcare (EBHC). The second aim was to start a database of such studies. The third aim was to share learning and foster discussion from the workshop through journal publication. EBM and EBHC are used interchangeable throughout this article. Working in eight small groups (three to five people), teachers and researchers of EBM/EBHC (n=29) first listed any articles that they considered useful for new teachers starting out their teaching journey. So that the challenge also acted as learning for the participants, they were deliberately not briefed on the full nature of the workshop (eg, the consideration and selection of specific articles). After 15 min, each group spent another 10 min selecting their top three articles from their original list (if this list had more than three papers). This was followed by another 5 min selecting their final article to put forward for this paper consensus and any disagreements resolved via discussion. Groups had to provide the following information for each paper: authors; year of publication; title; reason(s) for inclusion; link to paper/reference. Learning from previous experiences, the workshop lead (DN) instructed that a group could not select an article for which a group member was an author thus avoiding one possible source of conflict. As a group we felt that this specific rule of the article selection process …

Research question: Are large ovarian endometriomas associated with high pre-operative anti-Müllerian hormone (AMH) concentrations? Design: Data from 332 women who underwent AMH measurement before surgery for endometriosis were prospectively recorded in a large database. Univariate analysis compared AMH concentrations in terms of the patients’ baseline characteristics. A multivariate model was used to identify variables having an independent relationship with AMH concentration. Results: Among 332 women included in the study, 47.6% were aged 18–30 years, 67.8% were infertile and 85.5% were nulliparous. A total of 66.3% had ovarian endometriomas, and 10.8% had cysts measuring over 6 cm. Bilateral cysts over 3 cm were recorded in 24.7% of the women. Univariate analysis identified two variables that had a statistically significant relationship with AMH concentration: the woman's age (P = 0.01) and cyst size (P < 0.001). Multivariate analysis revealed that ages of 36–40 years and over 40 years showed a significant association with lower AMH concentrations (P = 0.02 and P = 0.009, respectively), while a cyst size of over 6 cm was statistically associated with high AMH concentrations (P < 0.001), after adjustment for smoking, parity, rectosigmoid endometriotic nodules and a bilateral location of endometriomas. Conclusions: Pre-operative AMH concentration was significantly increased in women with large endometriomas of over 6 cm, independent of their age or the presence of bilateral endometriomas. This is relevant for both surgeons and patients when planning surgery in women with an intention to conceive post-operatively.

The authors present their experience in ultrasound patterns of primary and recurrent endometrioma and correspondence with histopathological results, using 2D and color Doppler ultrasound examination. Cases of primary and recurrent endometriomas, as well as other false positive diagnosis are presented. The presence of the peripheral, healthy ovarian tissue, is the principal difference between the primary endometrioma and their recurrence. The arousal of papillary projections or solid-type echostructure decreases the likelihood of an endometrioma without histological atypia. Postmenopause modifies the ultrasound features of endometrioma by decreasing homogeneity and echogenicity

Objective: To demonstrate the relationship between intra-abdominal hypertension (IAH) and cardiac output (CO) in mechanically ventilated (MV), critically ill patients. Material and methods: This was a single-center, prospective study performed between January and April 2016, on 30 mechanically ventilated patients (mean age 67.3 ± 11.9 years), admitted in the Intensive Care Unit (ICU) of the Emergency County Hospital of Tîrgu Mureș, Romania, who underwent measurements of intra-abdominal pressure (IAP). Patients were divided into two groups: group 1 – IAP 12 mmHg (n = 9). In 23 patients who survived at least 3 days post inclusion, the variation of CO and IAP between baseline and day 3 was calculated, in order to assess the variation of IAP in relation to the hemodynamic status. Results: IAP was 8.52 ± 1.59 mmHg in group 1 and 19.88 ± 8.05 mmHg in group 2 (p Conclusions: CO is significantly correlated with IAP in mechanically ventilated patients, and IAH reduction is associated with increase of CO in these critically ill cases.

What is presently known is that thromboembolic disease represents a major cause of morbidity and mortality during pregnancy. To this we add a rare but not negligible pathology, acquired and inherited thrombophilia, which increases the predisposition for thrombotic events during pregnancy. In this article, what has been studied is the impact that LMWH has on patients with inherited thrombophilia, both the conventional FV, FII and the newly introduced MTHFR, PAI, FXII, factors which are often combined.81 patients have been taken into consideration / included in study, with the following anterior results, before the patients discovered their illnesses, thus before following treatment: first trimester or advanced pregnancy loss, IUGR, premature birth or secondary placental thrombotic complications such as: preeclampsia, DPPNI or dead fetuses, as well as maternal thrombotic accidents. The administration of LMWH decreased the rate of pregnancy loss compared to untreated pregnancies is statistical significant (p= 0.004), there were fewer DPPNI (p= 0.006), and no intrauterine deaths. We also compared the occurrence of thrombotic events during treated and untreated pregnancies and we observed significant differences in this groups (p= 0.001). There was also a sufficient number of patients with new types of thrombophilia included in the study to demonstrate the impact it has on pregnancy. LMWH improves the situation of women with thrombophilia during pregnancy.

BACKGROUND Although survival of preterm infants has improved, prematurity remains the second most frequent cause of death before 5 years of age in Romania. Data on the changing mortality of Romanian preterm infants born before 29 weeks of gestation have not been available. METHODS Outcomes of infants of gestational age 25-28 weeks born in 2007-2010 (n = 247) were compared with those born in 2011-2014 (n = 235). Data were analyzed from three tertiary neonatal intensive care centers. Mortality rates and major morbidities were compared between these two epochs. RESULTS Infants in the later epoch were more likely to have been born by cesarean section and had higher 1 and 5 min Apgar scores. Mortality rate decreased significantly with increasing gestational age at birth. Between the two epochs, the in-hospital mortality rate decreased from 65.6% to 29.4% (P

The aim of this study was to evaluate the correlation between serum and tissue level of the Neutrophil gelatinase-associated lipocalin (NGAL), a peptide that seems to be predict the postoperative evolution of patients with high abdominal pressure. From 30 consecutive patients hospitalized in the Intensive Care Unit, we have randomly selected five cases that undergo abdominal surgical interventions, received postoperative mechanical ventilation and abdominal pressure was monitorized for at least 48 hours. In all of these cases, the plasmatic level of NGAL was measured using the Elisa method and immunohistochemical (IHC) stains with the anti-NGAL biomarker were performed in the surgically removed tissues. All of the five patients were overweight, showed high serum level of NGAL (over 950 ng/ml) and died with postoperative or septic shock. The NGAL serum level was not correlated with the abdominal pressure. No IHC positivity was observed in the examined tissues, except NGAL positivity for intravascular neutrophils. In conclusion, the postoperative high serum NGAL level may indicate unfavorable evolution. NGAL seems to be syntesized by the circulating neutrophils and its preoperative tissue expression does not reflect the serum value.

The diagnosis of fetal cerebral hemorrhage (HCF) is less reported (0,9/1000 births) in comparison to the postpartum one. We presented 2 cases of fetal intraventricular hemorrhages diagnosed. Case 1: HCF diagnosed by ultrasound at the gestational age of 28 weeks and confirmed after birth by the presence of erythrocytes (significant number, pathological aspect) in the spinal fluid and by the modifications signaled by the transfontanellar ultrasound (severe internal hydrocephaly, minimum cerebral tissue). The death occurred after 24 hours postpartum (pathological exam: intraventricular cerebral hemorrhage). We mention the apparent lack of maternal risk factors, negative TORCH tests. Case 2: internal hydrocephaly at the age of 37 gestational weeks and confirmed in newborn (after cesarean section) by the clinical characteristic modifications, severe neurological impairment with modification at the transfontanellar ultrasound and the hemorrhagic and hypertensive aspect of the spinal fluid. We did not encounter maternal risk factors. Also, apparently, there were not any fetal risks: weight 2,820 grams at 37 gestational weeks, negative TORCH tests, negative cultures and CRP. The hydrocephaly had a progressive evolution imposing ventriculostomies and cysternotomies; the placement of a ventriculoperitoneal shunt during the third neurosurgical intervention improved the vital prognosis. Conclusions. The presence of hydrocephaly was a faithful ultrasound sign for the diagnosis of HCF. The evolution and the prognosis are influenced by the severity of hemorrhage and the gestational age. The survivors benefit from neurosurgical treatment. The multifactorial etiology, of the HCF incompletely elucidated leads to difficulties in establishing a target group of screening, in order to identify this lesion.

Background Uterine fibroids occur in up to 40% of women aged over 35 years. Some are asymptomatic, but up to 50% cause symptoms that warrant therapy. Symptoms include anaemia caused by heavy menstrual bleeding, pelvic pain, dysmenorrhoea, infertility and low quality of life. Surgery is the first choice of treatment. In recent years, medical therapies have been used before surgery to improve intraoperative and postoperative outcomes. However, such therapies tend to be expensive. Fibroid growth is stimulated by oestrogen. Gonadotropin-hormone releasing analogues (GnRHa) induce a state of hypo-oestrogenism that shrinks fibroids , but has unacceptable side effects if used long-term. Other potential hormonal treatments, include progestins and selective progesterone-receptor modulators (SPRMs). This is an update of a Cochrane Review published in 2000 and 2001; the scope has been broadened to include all preoperative medical treatments. Objectives To assess the effectiveness and safety of medical treatments prior to surgery for uterine fibroids. Search methods We searched the Cochrane Gynaecology and Fertility Group specialised register, CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL in June 2017. We also searched trials registers (ClinicalTrials.com; WHO ICTRP), theses and dissertations and the grey literature, handsearched reference lists of retrieved articles and contacted pharmaceutical companies for additional trials. Selection criteria We included randomised comparisons of medical therapy versus placebo, no treatment, or other medical therapy before surgery, myomectomy, hysterectomy or endometrial resection, for uterine fibroids. Data collection and analysis We used standard methodological procedures expected by The Cochrane Collaboration. Main results We included a total of 38 RCTs (3623 women); 19 studies compared GnRHa to no pretreatment (n = 19), placebo (n = 8), other medical pretreatments (progestin, SPRMs, selective oestrogen receptor modulators (SERMs), dopamine agonists, oestrogen receptor antagonists) (n = 7), and four compared SPRMs with placebo. Most results provided low-quality evidence due to limitations in study design (poor reporting of randomisation procedures, lack of blinding), imprecision and inconsistency. GnRHa versus no treatment or placebo GnRHa treatments were associated with reductions in both uterine (MD -175 mL, 95% CI -219.0 to -131.7; 13 studies; 858 participants; I² = 67%; low-quality evidence) and fibroid volume (heterogeneous studies, MD 5.7 mL to 155.4 mL), and increased preoperative haemoglobin (MD 0.88 g/dL, 95% CI 0.7 to 1.1; 10 studies; 834 participants; I² = 0%; moderate-quality evidence), at the expense of a greater likelihood of adverse events, particularly hot flushes (OR 7.68, 95% CI 4.6 to 13.0; 6 studies; 877 participants; I² = 46%; moderate-quality evidence). Duration of hysterectomy surgery was reduced among women who received GnRHa treatment (-9.59 minutes, 95% CI 15.9 to -3.28; 6 studies; 617 participants; I² = 57%; low-quality evidence) and there was less blood loss (heterogeneous studies, MD 25 mL to 148 mL), fewer blood transfusions (OR 0.54, 95% CI 0.3 to 1.0; 6 studies; 601 participants; I² = 0%; moderate-quality evidence), and fewer postoperative complications (OR 0.54, 95% CI 0.3 to 0.9; 7 studies; 772 participants; I² = 28%; low-quality evidence). GnRHa appeared to reduce intraoperative blood loss during myomectomy (MD 22 mL to 157 mL). There was no clear evidence of a difference among groups for other primary outcomes after myomectomy: duration of surgery (studies too heterogeneous for pooling), blood transfusions (OR 0.85, 95% CI 0.3 to 2.8; 4 studies; 121 participants; I² = 0%; low-quality evidence) or postoperative complications (OR 1.07, 95% CI 0.43 to 2.64; I² = 0%; 5 studies; 190 participants; low-quality evidence). No suitable data were available for analysis of preoperative bleeding. GnRHa versus other medical therapies GnRHa was associated with a greater reduction in uterine volume (-47% with GnRHa compared to -20% and -22% with 5 mg and 10 mg ulipristal acetate) but was more likely to cause hot flushes (OR 12.3, 95% CI 4.04 to 37.48; 5 studies; 183 participants; I² = 61%; low-quality evidence) compared with ulipristal acetate. There was no clear evidence of a difference in bleeding reduction (ulipristal acetate 5 mg: OR 0.71, 95% CI 0.3 to 1.7; 1 study; 199 participants; moderate-quality evidence; ulipristal acetate 10 mg: OR 0.39, 95% CI 0.1 to 1.1; 1 study; 203 participants; moderate-quality evidence) or haemoglobin levels (MD -0.2, 95% CI -0.6 to 0.2; 188 participants; moderate-quality evidence). There was no clear evidence of a difference in fibroid volume between GnRHa and cabergoline (MD 12.71 mL, 95% CI -5.9 to 31.3; 2 studies; 110 participants; I² = 0%; low-quality evidence). The included studies did not report usable data for any other primary outcomes. SPRMs versus placebo SPRMs (mifepristone, CDB-2914, ulipristal acetate and asoprisnil) were associated with greater reductions in uterine or fibroid volume than placebo (studies too heterogeneous to pool) and increased preoperative haemoglobin levels (MD 0.93 g/dL, 0.5 to 1.4; 2 studies; 173 participants; I² = 0%; high-quality evidence). Ulipristal acetate and asoprisnil were also associated with greater reductions in bleeding before surgery (ulipristal acetate 5 mg: OR 41.41, 95% CI 15.3 to 112.4; 1 study; 143 participants; low-quality evidence; ulipristal acetate 10 mg: OR 78.83, 95% CI 24.0 to 258.7; 1 study; 146 participants; low-quality evidence; asoprisnil: MD -166.9 mL; 95% CI -277.6 to -56.2; 1 study; 22 participants; low-quality evidence). There was no evidence of differences in preoperative complications. No other primary outcomes were measured. Authors' conclusions A rationale for the use of preoperative medical therapy before surgery for fibroids is to make surgery easier. There is clear evidence that preoperative GnRHa reduces uterine and fibroid volume, and increases preoperative haemoglobin levels, although GnRHa increases the incidence of hot flushes. During hysterectomy, blood loss, operation time and complication rates were also reduced. Evidence suggests that ulipristal acetate may offer similar advantages (reduced fibroid volume and fibroid-related bleeding and increased haemoglobin levels) although replication of these studies is advised before firm conclusions can be made. Future research should focus on cost-effectiveness and distinguish between groups of women with fibroids who would most benefit.

Diagnosticul antepartum al hemoragiei cerebrale fetale (HCF) este mai puţin raportat (0,9/1.000 naşteri) comparativ cu cel postpartum. Sunt prezentate două cazuri de hemoragie intraventriculară fetală, diagnosticate ecografic antepartum. Cazul 1: HCF diagnosticată ecografic la vârsta gestaţională de 28 de săptamâni de gestaţie şi confirmată postnatal prin prezenţa în LCR a hematiilor (număr semnificativ, ratatinate) şi a modificărilor semnalate de ecografia transfontanelară (hidrocefalie internă severă, ţesut cerebral minim). Decesul a survenit la 24 de ore postpartum (ex. histopatologic: hemoragie cerebrală intraventriculară). Menţionăm absenţa aparentă a factorilor de risc materni, negativitatea testelor TORCH. Cazul 2: hidrocefalie internă la vârsta de 37 de săptămâni de gestaţie şi confirmată la nou-născut (după cezariană) de modificările clinice caracteristice, suferinţa neurologică severă asociată cu modificări la ecografia transfontanelară şi aspectul hemoragic şi hipertensiv al LCR. Nu au fost depistaţi factori de risc materni. De asemenea, aparent nu au existat riscuri fetale: greutatea 2.820 g la 37 de săptămâni de gestaţie, teste TORCH negative, culturi şi CRP negative. Hidrocefalia a avut o evoluţie progresivă impunând ventriculotomii şi cisternotomii; plasarea unui şunt ventriculo-peritoneal în timpul celei de-a treia intervenţii neurochirurgicale a ameliorat prognosticul vital. Concluzii. Prezenţa hidrocefaliei a fost un semn ecografic fidel pentru diagnosticul HCF. Evoluţia şi prognosticul sunt influenţate de severitatea hemoragiei şi de vârsta gestaţională. Supravieţuitorii beneficiază de tratamentul neurochirurgical. Etiopatogenia plurifactorială, incomplet descifrată a HCF conduce la dificultăţi în stabilirea unui grup ţintă de screening, în scopul identificării acestei leziuni.

Background Birth before 28 weeks of gestation is associated with high mortality and morbidity. The purpose of this study was to examine characteristics associated with in-hospital mortality and morbidity among extremely low-birthweight neonates admitted to three tertiary care centers in Romania. Methods The study was conducted in three Romanian hospitals with level-III neonatal intensive care units. We studied singleton live births at the established Romanian limit of viability (i.e., 25–28 weeks' gestational age) born between January 2007 and December 2010 (n = 227). Infants born in non-level-III facilities transferred to these three centers were included in our study (n = 39). Descriptive and multivariate statistical analyses were used to describe the population and examine outcomes and risk factors. Results During the study period, 62 neonates (27.3%) were delivered at 25 weeks, 56 (24.7%) were delivered at 26 weeks, 56 (24.7%) at 27 weeks, and 53 (23.3%) at 28 weeks. Overall in-hospital mortality was 65% (from 85% at 25 weeks to 35% at 28 weeks). The rates for major morbidities were necrotizing enterocolitis 8.8%, bronchopulmonary dysplasia 12.5%, and retinopathy of prematurity (stage higher than 2) 26.2%. Conclusions During 2007–2010, in-hospital survival of infants admitted to three neonatal intensive care units in Romania was 35% and ranged from 14% at 25 weeks to 64% at 28 weeks.

Study Objective To compare the probability of postoperative pregnancy in infertile women with ovarian endometrioma larger than 3 cm in diameter, managed by either ablation using plasma energy or cystectomy. Design A multicentric case-control study (Canadian Task Force classification II-2). Setting Six surgical departments, affiliated with 4 university hospitals and 2 private facilities. Patients One hundred four infertile patients with ovarian endometrioma larger than 3 cm. Interventions Endometrioma ablation using plasma energy was performed in 64 patients (61.5%) and cystectomy in 40 patients (38.5%). Measurements and Main Results Patients were enrolled in the CIRENDO prospective cohort database (NCT02294825) from June 2009 to June 2014 and managed in 6 different facilities. The minimum length of follow-up was 1 year. Postoperative probabilities of pregnancy in patietns and control subjects were estimated using the Kaplan-Meier method with 95% confidence intervals (CIs) and compared using the log-rank test. The Cox model was used to assess independent predictive factors for pregnancy. Patients managed by plasma energy were significantly older than patients managed by cystectomy, had significantly higher overall revised American Fertility Society (rAFS) score, and had higher rate of Douglas pouch obliteration, deep endometriosis, and colorectal localizations. After a mean follow-up of 35.3 ± 17.5 months (range, 12–60), fertility outcomes were comparable between the groups. The probability of pregnancy at 24 and 36 months after surgery in plasma energy and cystectomy groups was, respectively, 61.3% (95% CI, 48.2%–74.4%) versus 69.3% (95% CI, 54.5%–83%) and 84.4% (95% CI, 72%–93.4%) versus 78.3% (95% CI, 63.8%–90%). The Cox's model revealed that the type of surgical procedure on ovarian endometrioma had no statistically significant impact on the probability of pregnancy, after adjustment for women's age, bilateral cysts larger than 3 cm, colorectal endometriosis, and rAFS stage of endometriosis. Conclusion Postoperative pregnancy rates were comparable after management of ovarian endometrioma by either ablation using plasma energy or cystectomy despite an overall higher rate of unfavorable fertility predictive factors in women managed by ablation.

The relationship between deep fibrotic endometriosis of the rectum and digestive symptoms as well as the impact of surgical treatment on digestive complaints appears increasingly complex. With the exception of cases in which the disease leads to rectal stenosis, it seems likely that certain digestive symptoms are a result of cyclic inflammatory phenomena leading to irritation of the digestive tract and not necessarily the result of actual involvement of the rectum by the disease itself because they frequently occur in women free of rectal nodules. Functional or inflammatory bowel diseases and rectal hypersensitivity may be associated with pelvic endometriosis and consequently joepardize the hypothetical causal relationship between the presence of a rectal nodule and digestive complaints. Women treated surgically for rectal endometriosis may continue to experience postoperative digestive complaints, such as constipation. Despite successful surgery free of intra- and postoperative complications and significant improvement in well-being and pelvic pain, several unpleasant digestive symptoms may be incompletely cured by the surgery. Furthermore, de novo postoperative digestive complaints may occur after rectal surgery. Retrospective data suggest that performing colorectal resection is related to less favorable digestive functional outcomes than the use of conservative procedures such as shaving or full-thickness disc excision. These hypotheses need to be confirmed by prospective randomized trials comparing rectal radical and conservative approaches. Bearing in mind the complex relationship between rectal nodules, digestive symptoms and rectal surgery, particular care must be taken in the preoperative assessment of digestive function and in choosing the most suitable surgical procedure.

Objective To determine the prevalence of abnormal cervical smears in a previously unscreened and asymptomatic population in Romania and to compare the data with those from other countries in Europe. Methods In a retrospective study, data were reviewed from smears obtained from women in Romania who had been referred to the gynecologist between January 2006 and December 2011. The smears were collected through 3 regional opportunistic programs of cervical screening and were classified according to the Bethesda system. Results During the study period, 50 536 smear tests were carried out. Of these, 100 smears (0.2%) were unsatisfactory and excluded from the study. Among the remaining 50 436 smears, 2965 patients (5.9%) had abnormal epithelial changes. Most of the abnormal smears were represented by atypical squamous cells of undetermined significance (2.6% of all smears). The data confirmed that there is a high prevalence of high-grade intraepithelial squamous-type lesions (0.9% of all smears) in Romania, and of abnormal smears in women younger than 25 years of age (14.0% of all abnormal smears). Conclusion The data show that there is a high prevalence of epithelial abnormalities among cervical smears in Romania compared with other European countries that run a national screening program.

Study Objective To assess recurrence and pregnancy rates in women with ovarian endometrioma treated via ablation using plasma energy. Design Retrospective non-comparative pilot study including 55 patients treated during 28 months, with prospective recording of data (Canadian Task Force classification II-2). Setting Tertiary referral center. Patients Fifty-five consecutive women with pelvic endometriosis in whom ovarian endometriomas were managed solely via ablation using plasma energy. The minimum follow-up was 1 year. Intervention Endometrioma ablation using plasma energy. Measurements and Main Results Information was obtained from the database of the North-West Inter Regional Female Cohort for Patients with Endometriosis, based on self-questionnaires completed before surgery, surgical and histologic data, and systematic recording of recurrences, pregnancy, and symptoms. Recurrences were assessed using pelvic ultrasound examination. Mean (SD) follow-up was 20.6 (7.2) months (range, 12–39 months). In 75% of patients, deep infiltrating endometriosis was treated, and 40% had colorectal involvement. Preoperative infertility was recorded in 42% of patients. The rate of postoperative recurrence was 10.9% for the entire series. Of 33 women who wished to conceive, 67% became pregnant, spontaneously in 59%. Time from surgery to the first pregnancy was 7.6 (4.3) months. After discontinuation of postoperative hormone therapy, the probability of not conceiving at 12 months was 0.36 (95% confidence interval, 0.19–0.53), and at 24 months was 0.27 (95% confidence interval, 0.12–0.44). Conclusions Recurrence and pregnancy rates are encouraging in that they seem comparable to the best reported results after endometrioma cystectomy. Plasma energy may have an important role in the management of ovarian endometrioma in women seeking to conceive. Patients most in need of surgical procedures that can spare ovarian parenchyma, such as those with bilateral endometriomas or a history of ovarian surgery, may particularly benefit from ablation using plasma energy.

Resume Objectifs Evaluer les connaissances des medecins generalistes dans la prise en charge de l’endometriose, dans les conditions du declin demographique des gynecologues medicaux. Population et methodes Cent medecins generalistes du departement de la Seine Maritime, region de la Haute Normandie, ont participe a une enquete concernant le diagnostic et la prise en charge therapeutique de l’endometriose. La selection des medecins a ete realisee en respectant les criteres de l’appartenance geographique et de la parite. Resultats Parmi les medecins generalistes interroges (MGI), 44 % effectuent plus d’une consultation gynecologique par semaine. Plus de deux-tiers des medecins generalistes se considerent peu ou pas du tout a l’aise dans la prise en charge de l’endometriose. Plus de la moitie des MGI ne peuvent pas citer trois des symptomes cardinaux de l’endometriose. Seulement 38 % des MGI pratiquent un examen clinique oriente en cas de suspicion d’endometriose. L’IRM n’est pratiquee en premiere intention que dans 28 % des cas. L’avis specialise est pris d’emble par 24 % des MGI et 57 % apres bilan et/ou test therapeutique, et seulement 52 % sollicitent cet avis aupres du centre hospitalier universitaire de Rouen. Concernant le traitement medical, 64 % des MGI sont d’accord que l’amenorrhee constitue la base du traitement. La participation a des formations gynecologiques au cours de derniers 5 ans et le suivi de plus de 3 femmes traitees pour une endometriose ont ete des facteurs associes a la probabilite de repondre correctement aux questions. Discussion et conclusion Les medecins generalistes ne semble pas suffisamment sensibilises a la problematique du diagnostic et de la prise en charge de l’endometriose, ce qui contribue probablement au retard diagnostique caracteristique de cette pathologie chronique. La participation a la formation continue en gynecologie et les echanges entre les specialistes et les medecins qui suivent les patientes deja traitees pour endometriose semblent ameliorer la qualite des reponses au questionnaire.

Resume Objectifs La chirurgie de l’endometriose profonde est responsable de diverses complications, comme l’apparition postoperatoire d’epanchements liquidiens infectes du cul-de-sac de Douglas. L’objectif de notre etude est de decrire ce type de complication et d’evaluer sa frequence dans la serie de notre departement. Patientes et methodes Etude retrospective incluant 163 femmes ayant beneficie d’une chirurgie d’endometriose profonde posterieure avec infiltration du fond vaginal, du janvier 2008 au septembre 2011. Nous avons identifie les femmes ayant presente un episode febrile associe a l’existence d’une image d’abces du cul-de-sac de Douglas a l’examen tomodensitometrique. Les caracteristiques et la prise en charge ont ete analysees dans chaque cas. Resultats Dix patientes ont presente une suspicion d’abces du cul-de-sac de Douglas manifestee par un syndrome inflammatoire survenu en moyenne six jours apres l’operation. Toutes les femmes presentaient une douleur pelvienne, une hyperthermie superieure a 38,5 °C, une hyperleucocytose, une elevation du taux de la proteine C reactive et un epanchement liquidien du cul-de-sac de Douglas. Une exploration chirurgicale a ete realisee chez neuf patientes, avec la mise en evidence d’un epanchement de liquide hematique trouble. Les prelevements bacteriologiques ont ete positifs dans 6 cas et ont suggere une contamination lors de l’ouverture vaginale. L’evolution postoperatoire a ete rapidement favorable. Discussion et conclusion La survenue d’un syndrome inflammatoire du a un epanchement liquidien infecte du cul-de-sac de Douglas est une complication postoperatoire immediate de la chirurgie de l’endometriose profonde posterieure du vagin. Sa prise en charge chirurgicale permet une amelioration clinique des le lendemain de l’intervention.

Objective To provide a mapping of bowel occult microscopic endometriosis implants from colorectal specimens removed from patients who had undergone colorectal resection for deep endometriosis infiltrating the rectum. Design A series of consecutive patients with deep endometriosis infiltrating the rectum or/and sigmoid colon, between January 2013 and December 2013. Setting University tertiary referral center. Patient(s) Twenty-six patients with deep endometriosis infiltrating the rectum or/and sigmoid colon. Intervention(s) Surgical management by colorectal resection. Main Outcome Measure(s) Twenty-six patients with prospective recording of data (age, clinical history, symptoms, preoperative assessment, and intraoperative findings) underwent colorectal resection for bowel endometriosis. Mapping of occult microscopic endometriosis implants from specimens was established by histologic examination of 1,051 microsection slides taken from transversal macrosections of 3-mm thickness (40 microsections per patient on average). Result(s) The mean (SD) length of colorectal specimens was 110 (42) mm. Microimplants were found at varying distances up to 54 mm from macronodule limits. Multiple macroscopic nodules were identified in five patients (19.2%). In 18 specimens (69%) diffusion of endometriosis microimplants was longitudinal, whereas in 8 specimens (31%) diffusion was concentrated around the macroscopic nodule. Respectively, 31%, 19%, 8%, and 4% of patients presented with endometriosis microimplants at 2, 3, 4, and 5 cm from macroscopic nodules. Conclusion(s) The present data suggest that in patients presenting with deep colorectal endometriosis, microscopically complete excision of rectal endometriosis may be unachievable because of bowel occult microscopic endometriosis implants located far from macroscopic nodules.

Introduction: Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named. Objectives: To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index. Material and method: This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point. Results: We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045). Conclusions: The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.

Tubo-ovarian abscesses are likely to occur in women suffering from deep endometriosis. The aim of surgical management of tubo-ovarian abscesses is the laparoscopic drainage, while deep endometriosis resection should be delayed. Laparoscopic procedure carried out in emergency does not attempt at the excision of deep endometriotic lesions, and must avoid the choice of the laparoconversion, in order to avoid further changes in the pelvic anatomy rendering more difficult a curative surgery. We report six cases of patients presenting tubo-ovarian abscesses arising on deep endometriosis, and we discuss the choice of the 2-step surgical management. In four cases, deep endometriosis resection has been performed by laparoscopic route few months after the drainage of abscess and provided macroscopically complete excision of the disease.

Study Objective To document the presence of bowel invisible microscopic endometriosis implants and their relationship with deep endometriosis macronodule infiltrating the bowel. Design A series of consecutive patients with deep endometriosis infiltrating the rectum and/or sigmoid colon (Canadian Task Force classification II-2). Settings A university referral center. Patients Ten patients managed by colorectal resection. Interventions A microscopic study of endometriotic foci of the bowel involving 3272 microsection slides was established using a unique method of step serial sections using combined transverse and longitudinal macrosection. Two-dimensional reconstruction based on slide scanning highlighted the presence and localization of the deep endometriosis macronodule in contrast with bowel invisible microscopic endometriosis microimplants. Measurements and Main Results The distance separating the microimplants and the nodule and their histologic characteristics. The mean length of the colorectal specimens was 91 ± 19 mm. The maximum distance between the farthest microimplants was 7.2 cm. The maximum distance from the macroscopic nodule limit to the farthest microimplant was 31 mm. Bowel invisible microscopic endometriosis microimplants presented with similar features independently of the type of spread. They had an active appearance including stroma and glands, were sometimes decidualized, and were free of fibrosis. They were found on the distal/rectal limit of the specimen in 3 patients and on both limits (distal/rectal and proximal/sigmoid colon) in 1 patient. Conclusion Invisible microscopic endometriosis implants surround the bowel macroscopic endometriosis nodule at variable distances, suggesting that complete surgical microscopic removal may be a challenging goal. These results may help to reconsider the principles and feasibility of the surgical management of bowel endometriosis.

El objetivo de este articulo es presentar las tecnicas que se utilizan en la cirugia de los endometriomas del ovario. El tratamiento quirurgico de los endometriomas esta justificado en caso de dolor pelvico ciclico o cronico, de infertilidad y debido al riesgo de complicaciones. Los endometriomas no influyen sobre el resultado final de una fecundacion in vitro (FIV). El descubrimiento de un endometrioma durante una estimulacion de FIV en una mujer sin sintomas dolorosos no requiere que se interrumpa el intento ni necesita un tratamiento quirurgico reiterado o la puncion de los endometriomas. Las tecnicas quirurgicas de exeresis o de ablacion de los endometriomas deben tener en cuenta las teorias que explican la formacion y el desarrollo de los endometriomas por la invaginacion en el tejido ovarico. En consonancia con estas teorias, el acceso al endometrioma debe hacerse por el punto de origen de la invaginacion y no por la incision antimesial clasica, que se utiliza en la cirugia de los quistes del ovario de otra naturaleza. Ningun ensayo aleatorizado ha comparado la exeresis del quiste con la ablacion de la pared quistica mediante vaporizacion con laser de CO2. La quistectomia deberia llevarse a cabo teniendo en cuenta la existencia de tres zonas distintas en el interior del endometrioma. En la mayoria de los casos, la quistectomia provoca la perdida de una cantidad variable de tejido ovarico subyacente a la pared del quiste, sobre todo frente al hilio ovarico. La ablacion del quiste con ayuda de corriente bipolar se asocia a una tasa de recidivas superior a la quistectomia. La anexectomia puede plantearse solo en las mujeres que no deseen mas embarazos. La utilidad del tratamiento preoperatorio aun esta en entredicho. El tratamiento postoperatorio administrado de forma continua a largo plazo disminuye de forma significativa la tasa de recidiva de los endometriomas y deberia proponerse de forma sistematica a las mujeres que no deseen gestaciones en un periodo inmediato.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 37 - N° 8S1 - p. 405-417

Objective To discuss the risk of bowel occlusion or subocclusion in patients with pregnancy wish and deep colorectal endometriosis, when surgery is postponed until after conception. Design A prospective series of consecutive patients managed for occlusion or subocclusion between January 2012 and January 2015 (Canadian Task Force classification II-2). Deep endometriosis had previously been diagnosed in all patients; however, they were advised to postpone surgery until after conception. Setting University tertiary referral center. Patients Twelve women with bowel occlusion or subocclusion due to deep endometriosis and desiring pregnancy. Intervention Surgical management including colorectal resection. Main Outcome Measures Digestive symptoms, including standardized gastrointestinal questionnaires and preoperative imaging assessment of deep endometriosis. Results The patients enrolled in the series represent 5% of 241 patients with colorectal endometriosis managed over 37 consecutive months. Major digestive complaints were bloating, defecation pain, constipation, liquid stools, and a feeling of incomplete stool evacuation. The median length of digestive tract stenosis was 50 mm (range, 20–100 mm). In 8 patients (67%), computed tomography–based virtual colonoscopy revealed a virtual digestive lumen. The median length of colorectal specimen removed was 120 mm (range, 60–200 mm). Three patients (25%) had Clavien-Dindo IIIb and IVa postoperative complications with favorable outcomes within up to 20 days after surgery. Conclusion Given the risk of bowel occlusion or subocclusion in young patients with colorectal endometriosis, an exhaustive assessment of deep disease and advice at a tertiary referral center appears to be mandatory before prioritizing primary in vitro fertilization instead of primary surgery.

Birth before 28 weeks of gestation is associated with high mortality and morbidity. The purpose of this study was to examine characteristics associated with in-hospital mortality and morbidity among extremely low-birthweight neonates admitted to three tertiary care centers in Romania.The study was conducted in three Romanian hospitals with level-III neonatal intensive care units. We studied singleton live births at the established Romanian limit of viability (i.e., 25-28 weeks' gestational age) born between January 2007 and December 2010 (n = 227). Infants born in non-level-III facilities transferred to these three centers were included in our study (n = 39). Descriptive and multivariate statistical analyses were used to describe the population and examine outcomes and risk factors.During the study period, 62 neonates (27.3%) were delivered at 25 weeks, 56 (24.7%) were delivered at 26 weeks, 56 (24.7%) at 27 weeks, and 53 (23.3%) at 28 weeks. Overall in-hospital mortality was 65% (from 85% at 25 weeks to 35% at 28 weeks). The rates for major morbidities were necrotizing enterocolitis 8.8%, bronchopulmonary dysplasia 12.5%, and retinopathy of prematurity (stage higher than 2) 26.2%.During 2007-2010, in-hospital survival of infants admitted to three neonatal intensive care units in Romania was 35% and ranged from 14% at 25 weeks to 64% at 28 weeks.

The efficacy and safety of oral ulipristal acetate for the treatment of symptomatic uterine fibroids before surgery are uncertain.We randomly assigned women with symptomatic fibroids, excessive uterine bleeding (a score of100 on the pictorial blood-loss assessment chart [PBAC, an objective assessment of blood loss, in which monthly scores range from 0 to500, with higher numbers indicating more bleeding]) and anemia (hemoglobin level of ≤10.2 g per deciliter) to receive treatment for up to 13 weeks with oral ulipristal acetate at a dose of 5 mg per day (96 women) or 10 mg per day (98 women) or to receive placebo (48 women). All patients received iron supplementation. The coprimary efficacy end points were control of uterine bleeding (PBAC score of75) and reduction of fibroid volume at week 13, after which patients could undergo surgery.At 13 weeks, uterine bleeding was controlled in 91% of the women receiving 5 mg of ulipristal acetate, 92% of those receiving 10 mg of ulipristal acetate, and 19% of those receiving placebo (P0.001 for the comparison of each dose of ulipristal acetate with placebo). The rates of amenorrhea were 73%, 82%, and 6%, respectively, with amenorrhea occurring within 10 days in the majority of patients receiving ulipristal acetate. The median changes in total fibroid volume were -21%, -12%, and +3% (P=0.002 for the comparison of 5 mg of ulipristal acetate with placebo, and P=0.006 for the comparison of 10 mg of ulipristal acetate with placebo). Ulipristal acetate induced benign histologic endometrial changes that had resolved by 6 months after the end of therapy. Serious adverse events occurred in one patient during treatment with 10 mg of ulipristal acetate (uterine hemorrhage) and in one patient during receipt of placebo (fibroid protruding through the cervix). Headache and breast tenderness were the most common adverse events associated with ulipristal acetate but did not occur significantly more frequently than with placebo.Treatment with ulipristal acetate for 13 weeks effectively controlled excessive bleeding due to uterine fibroids and reduced the size of the fibroids. (Funded by PregLem; ClinicalTrials.gov number, NCT00755755.).

This study suggests that bladder and rectal dysfunction occur more frequently with colorectal resection in rectal endometriosis compared with excision of the nodules alone., Background: To evaluate intra- and postoperative complications associated with laparoscopic management of rectal endometriosis by either colorectal segmental resection or nodule excision. Methods: During 39 consecutive months, 46 women underwent laparoscopic management of rectal endometriosis and were included in a retrospective comparative study. The distinguishing feature of the study is that the choice of the surgical procedure is not related to the characteristics of the nodule. Results: Colorectal segmental resection with colorectal anastomosis was carried out in 15 patients (37%), while macroscopically complete rectal nodule excision was performed in 31 women (63%). No intraoperative complications were recorded. In the colorectal resection group, 3 women (18%) had a bladder atony (spontaneously regressive in 2 women), 4 women (24%) experienced chronic constipation, one had an anastomosis leakage (6%), while 2 women (13%) had acute compartment syndrome with peripheral sensory disturbance. In the nodule excision group, 1 woman (4%) developed transitory right obturator nerve motor palsy. Based on both postoperative pain and improvement in quality of life, all 29 women in the excision group (100%) and 14 women in the colorectal resection group (82%) would recommend the surgical procedure to a friend suffering from the same disease. Conclusion: Our study suggests that carrying out colorectal segmental resection in rectal endometriosis is associated with unfavourable postoperative outcomes, such as bladder and rectal dysfunction. These outcomes are less likely to occur when rectal nodules are managed by excision. Information about complications related to both surgical procedures should be provided to patients managed for rectal endometriosis and should be taken into account when a decision is being made about the most appropriate treatment of rectal endometriosis in each case.

A 42-year-old patient had a stage III ovarian endometrioid adenocarcinoma with areas of hepatoid carcinoma (HC) of clear cell and eosinophilic pseudoglandular type that was difficult to differentiate from endometrioid carcinoma of oxyphilic type and sex cord-stromal tumor. Immunohistochemically, endometrioid adenocarcinoma was positive for CA125, estrogen and progesterone receptors, CAM5.2, cytokeratin (CK) 7 and 19, and vimentin. HC areas were positive for hep par1, polyclonal carcinoembryonic antigens, CD10, alpha-fetoprotein, epithelial membrane antigens, and antimitochondrial antibodies and shared with endometrioid carcinoma focal CK7, and constant positive CK19, CAM5.2, and progesterone receptors. In the differential diagnosis, a hepatic immunophenotype of oxyphilic, mitochondriae-rich areas (demonstrated by antimitochondrial antibodies) was identified by HC specific (hep par1) and characteristic markers: canalicular, cytoplasmic and membranous polyclonal carcinoembryonic antigens, CD10 patterns, and alpha-fetoprotein). Trabecular and clear vacuolated areas of HC resembled luteinized cells of sex cord-stromal ovarian tumors, but the membranous positivity to CAM5.2 supported epithelial (hepatoid) identity. The partial preservation of an endometrioid immunophenotype in HC (positive CK7 and 19 and progesterone receptors) would support an origin from endometrioid carcinoma.

A 73-year-old female presented with a left ovarian tumor mass. Microscopic examination disclosed cystic spaces lined by abundant clear and eosinophilic tumor cells with pleomorphic nuclei. Differential diagnosis included primary ovarian oxyphilic-type clear cell carcinoma and sex-cord tumor with extensive luteinization. However, analysis of the patient's past history revealed that in 2003, she had undergone nephrectomy for a papillary renal cell carcinoma, and a histological comparison between the primary and the present tumor exhibited in the latter a substantially larger number of clear cells and loss of papillary architecture. Immunohistochemistry demonstrated a characteristic renal immunophenotype for a type II tubulopapillary tumor metastatic to ovary. The tumor cells were strongly positive for CD10 and AMACR, and negative for cytokeratin 7. This confirmed the renal origin of the ovarian tumor despite its divergent morphology of the renal primary. This is the first reported case of ovarian metastases of type II tubulopapillary carcinoma of the kidney.

Objective: To investigate the impact of ovarian endometrioma vaporization using plasma energy on antimullerian hormone (AMH) level. Method: We report a prospective, noncomparative series (NCT01596985). Twenty-two patients with unilateral ovarian endometriomas ≥30 mm, with no surgical antecedent and no ongoing pregnancy, underwent vaporization of ovarian endometriomas using plasma energy during the period of November 29, 2010 to November 28, 2012. We assessed AMH levels before surgery, 3 months postoperatively, and at the end of follow-up. Results: The mean length of postoperative follow-up was 18.2 ± 8 months. AMH level significantly varied through the 3 assessments performed in the study, as the mean values ± SD were 3.9 ± 2.6 ng/mL before the surgery, 2.3 ± 1.1 ng/mL at 3 months, and 3.1 ± 2.2 ng/mL at the end of the follow-up (P = .001). There was a significant increase from 3 months postoperatively to the end of follow-up (median change 0.7 ng/mL, P = .01). Seventy-one percent of patients had an AMH level >2 ng/mL at the end of the follow-up versus 76% before the surgery (P = 1). During the postoperative follow-up, 11 patients tried to conceive, of whom 8 (73%) became pregnant. Conclusions: The ablation of unilateral endometriomas is followed in a majority of cases by a significant decrease in AMH level 3 months after surgery. In subsequent months, this level progressively increases, raising questions about the real factors that impact postoperative ovarian AMH production.