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Objective The study aimed to assess the efficacy of abdominal compression and pulmonary recruitment maneuver (CPRM) after transvaginal natural orifice transluminal endoscopic surgery (vNOTES) to alleviate post-laparoscopic shoulder pain (PLSP). Materials and methods In this retrospective cross-sectional study conducted in a tertiary referral medical center, women who underwent vNOTES between January 2018 and May 2019 were classified into control group and CPRM group with CO2 force expelled. Data on the demographic characteristics, indications for surgery, and surgical history were collected. Postoperative pain was assessed 24 and 48 h postoperatively using the visual analog scale (VAS, 0–10). Chest radiography was used to determine the residual air volume 24 h after surgery. Results Of 10 patients, 6 and 4 underwent vNOTES adnexal surgeries and vNOTES hysterectomy, respectively. The median volumes of residual pneumoperitoneum were 9.02 mL and 28.11 mL in the CPRM and control groups, respectively (p = 0.001). The intensity of PLSP in the CPRM and control groups were 0 ± 0 vs. 3.4 ± 3.4 and 0.4 ± 0.8 vs. 2.2 ± 2.2 24 and 48 h after surgery, respectively (p = 0.005 for 24 h and p = 0.04 for 48 h). Conclusion CPRM might facilitate decrease in residual gas volume and PLSP after vNOTES. CPRM might be considered using in vNOTES to decrease PLSP.

Objective To present a case of vulvar myoma and the factors differentiating this tumor from Bartholin's cyst. Case report A 50-year-old woman presented with a nodule over the left labia majora. Pelvic examination showed swelling and redness of the left labia majora. A 2-cm nodule with firm consistency was found near the vaginal opening. There was no inguinal lymphadenopathy. Bartholin's cyst was suggested, and oral cephalexin was prescribed for 1 week, but no improvement was seen. Therefore, she underwent excision of the nodule. Pathology revealed it to be a benign vulvar myoma. The patient recovered well, and no recurrence was noted after 2 months of follow-up. Conclusion Vulvar myoma is rare. Sexual history, nodule consistency, and imaging are helpful, but the final diagnosis of vulvar myoma is usually made following surgical excision and histopathological analysis.

Objective We present a rare case of well-differentiated papillary mesothelioma (WDPM) found incidentally in a 59-year-old woman with endometrial cancer. Case report A 59-year-old nulliparous obese woman with a past history of hypertension and diabetes mellitus presented with postmenopausal bleeding for 11 months. Two months prior to this admission, an episode of massive vaginal bleeding lasting for a day was noticed by the patient. Hysteroscopy was performed after her visit to our outpatient department. Papillary tumors with active bleeding were found in the uterine cavity. Endometrial biopsy showed adenocarcinoma, endometrioid type characterized by papillary architecture lined by columnar cells with mild nuclear pleomorphism. The patient proceeded to magnetic resonance imaging (MRI), which demonstrated a 6.4 × 5.5 × 4.9 cm intrauterine mass. Her tumor marker levels were elevated (CA 125 87.8 IU/ml, CA19-9160.54 IU/ml). The patient then underwent a staging surgery and final pathology revealed stage IA endometrial cancer. During surgery, multiple nodules were found in the peritoneum, initially considered as tumor metastasis and eventually proved to be WDPM. Conclusion In conclusion, the simultaneous occurrence of WDPM with endometrial cancer is a rare entity. Although no standardized treatment has been established, WDPMs have a relatively favorable prognosis compared to malignant mesotheliomas.

Objective The aim of the study was to propose a method using saline lubrication and two glass slides to reduce the proportion of inadequate Pap smears. Materials and methods This was a retrospective study of patients at a medical center in eastern Taiwan that performs 5000–6000 Pap smears annually. The extracted data only detailed the number and percentage of inadequate Pap smears. We applied two modifications to the conventional Pap smear technique. The first modification was lubricating the speculum with normal saline instead of jelly. The second modification was performing the smear on two glass slides instead of just one. We used the modified technique beginning in January 2017. Therefore, we collected data from 2016 (before the modified technique was employed) and 2018 (after the modified technique was employed). The categorical data are presented as numbers (percentages). The differences in the number and percentage of inadequate smears resulting from both techniques were assessed using the Chi-square test. Results During 2016 and 2018, 28 and 2 women received inadequate Pap smears among the total of 594 and 613 women who received Pap smears, respectively. The proportion of inadequate Pap smears was 4.71% and 0.33% in 2016 and 2018, respectively (P Conclusions The use of this modified technique effectively reduced the percentage of inadequate Pap smears.

This study aimed to evaluate fetal adverse outcomes of laparoscopy and laparotomy in pregnant women to determine the safety of these surgical approaches. This was a retrospective nationwide case–control study of women who became pregnant for the first time between 2000 and 2012 in Taiwan. The case (with adverse fetal outcomes) and control groups comprised 208,604 and 417,124 participants, respectively. Participants who underwent appendectomy, cholecystectomy, ovarian cystectomy, or myomectomy were treated with either laparoscopy or laparotomy. A conditional logistic regression model was used to calculate the odds ratios (ORs) for adverse fetal outcomes. The laparotomy and laparoscopy groups comprised 632 and 536 patients, respectively. Women who underwent laparoscopy had a significantly higher risk of adverse fetal outcomes (adjusted OR [AOR] = 2.33; 95% CI 1.66–2.99) than those who underwent laparotomy. Adverse fetal outcomes were found to be significantly associated with laparoscopy among women aged 20–39 years (AOR = 2.30; 95% CI 1.70–3.31). Regarding surgical indication, unlike laparotomy, laparoscopic cholecystectomy and appendectomy were not associated with adverse fetal outcomes. However, laparoscopic myomectomy and ovarian surgeries were associated with a higher incidence of adverse fetal outcomes than the laparotomy group (AOR = 2.29 [95% CI 1.57–3.35, p

Ovarian diffuse large B-cell lymphoma (DLBCL) is rare. DLBCL is a complex type of lymphoma. The ovarian DLBCL usually harbor a favorable prognosis. We report a case of ovarian DLBCL that presented as an ovarian mass with lower abdominal pain and was managed using laparoscopic staging surgery. A 29-year-old female (gravida 2, para 0, abortion 2) with a history of polycystic ovarian syndrome with irregular medication control visited our clinic due to lower abdominal pain. Transvaginal ultrasound revealed a heterogeneous, septated mass over the left adnexa with a diameter of approximately 6 cm × 8 cm. The tumor marker CA 19-9 was elevated (65.77 IU/mL); CA125 and carcinoembryonic antigen were not elevated. Laparoscopic surgery with left salpingo-oophorectomy was first performed. Frozen section indicated dysgerminoma. Then, we continued staging surgery through bilateral pelvic lymph node dissection, para-aortic lymph node dissection, omentectomy, right ovary and peritoneum biopsy, and washing cytology. Ovarian tumor and para-aortic lymph nodes were positive for lymphoma. The tumor cells were positive staining for CD20, CD5, ki67, BCL-6, and MUM-1, which was associated with DLBCL. The patient was then consulted for oocyte preservation and referred to hematology for further chemotherapy. In conclusion, an ovarian lymphoma is a rare event. The presence of an enlarged ovarian tumor should raise the suspicion of ovarian lymphoma. To differentiate ovarian lymphoma from dysgerminoma, immunohistochemistry is useful. Fertility preservation should be considered before chemotherapy. Ovarian tissue or oocyte preservation or gonadotropin-releasing hormone agonist injection before chemotherapy can be performed for fertility preservation.

We aim to evaluate breast cancer risk relating to PPIs usage in women with peptic ulcer. From 2000 to 2013, incidence rates of breast cancer were compared between the two cohorts (with or without PPIs). Each study cohort consisted of 4838 women. The incidence density rate of breast cancer in the PPI cohort was 0.29 that in the comparison cohort (10.0 vs 31.6 per 10 000 person-years), with an adjusted HR (hazard ratio) of 0.32 (95% CI = 0.20-0.49) for the PPI cohort. In conclusion, the medication of PPIs is associated with reduced breast cancer risk for women with gastric ulcer.

Objectives: The objective of this study is to compare the outcomes of laparoscopic hysteropexy (LHP) and laparoscopic supracervical hysterectomy plus cervicopexy (LSHCP) for the treatment of pelvic organ prolapse (POP). Materials and Methods: We retrospectively included patients who had undergone laparoscopic sacral hysteropexy or hysterectomy plus cervicopexy between January 2015 and May 2019 at Hualien Tzu Chi Hospital, Taiwan. Age at surgery, body mass index (BMI) at admission, the initial stage of genital prolapse, operative and postoperative data, and anatomical results were recorded. Cure for uterine prolapse was evaluated objectively through vaginal examinations using the POP quantification scale. Visual analog scale (VAS) scores were recorded at 24 h postoperatively. The Mann–Whitney U-test was used to compare continuous variables. Results: A total of 23 women were included in the study; 12 had received LHP (n = 12) and 11 had received LSHCP (n = 11). No differences existed in age, parity, BMI, blood loss, or hospital stay between groups. The difference in mean surgical times between the LHP and LSHCP groups was nonsignificant (154 and 176 min, respectively; P = 0.2). VAS scores were significantly lower in the LSHCP group than in the LHP group (0.1 vs. 1.75; P = 0.004). Furthermore, mean hospital stay was significantly longer in the LSHCP group than in the LHP group (4.0 vs. 3.1 days; P = 0.016). The procedure was successful in 100% of patients (23 of 23), with no objective evidence of uterine prolapse on examination at follow-up at 6 months. Conclusion: LHP had a significantly shorter hospital stay and a higher VAS score than LSHCP. LHP and LSHCP are both feasible and effective procedures for correcting uterine prolapse.

Endometriosis is a common systemic chronic inflammatory disease. Inflammation is the key mechanism responsible for the development of endothelial dysfunction and atherosclerosis. We aimed to investigate the risk of coronary artery disease (CAD) among Asian women with endometriosis. This retrospective population-based cohort study included patients with endometriosis diagnosed from 2000 to 2012 and registered in the Longitudinal Health Insurance Database, Taiwan. The comparison cohort (those without endometriosis) were selected (1:4) by matching the age frequency and the index year. We followed up the patients until the diagnosis of CAD (ICD-9-CM codes: 410–414, A270, and A279), withdrawal from the National Health Insurance system, death, or the end of the study. We used a multivariable-adjusted Cox proportional hazard model for evaluating the risk of CAD. We included 19,454 patients with endometriosis and 77,816 women as a comparison group. The mean age of the women at the diagnosis of endometriosis was 37.4 years. A total of 3245 women developed CAD in both groups during a median follow-up of 7 years. The incidence of CAD was higher in women with endometriosis than in those without (5.96 vs. 4.38 per 10,000 person-years, adjusted hazard ratio [95% confidence interval], 1.34 [1.22–1.47]). In conclusion, Asian women with endometriosis had a significantly higher risk of CAD. Further large-scale studies are needed to elucidate the cause-effect relationship between endometriosis and CAD.

Pelvic inflammatory disease (PID) affects 4.4% of women aged 18−44 in the United States, and may cause infertility if it is ineffectively treated. A combination of clindamycin and gentamicin is generally used for the treatment of PID. The benefit of adding metronidazole into the treatment combination still remains unclear, and this study was designed to evaluate its effectiveness. We retrospectively included 107 women who were diagnosed with PID from May 2013 to September 2020 in a single hospital. Based on their used antibiotic regimens, the patients were divided into three groups—those who were treated with clindamycin + gentamicin (group 1, n = 46), those who took regular antibiotics plus metronidazole (group 2, n = 27), and others (group 3, n = 34). Primary outcomes included the rates of taking surgery after failed antibiotics, occurrence/rupture of tubo-ovarian abscesses, and readmission within the following 6 months of first treatment. Secondary outcomes to assess were the length of stay (LOS) and expenditure for PID. There were no significant differences in the surgical rates, readmission rates, LOS and expenditure noted between the three groups. Subgroup analysis showed that visual analogue pain scores being 5 or more would increase the LOS by 3.83 days (p &lt, 0.001), and body temperature &gt, 38.3 °C or more would increase the treatment total expenditure (p &lt, 0.001). Our study results suggest that the combination of clindamycin + gentamicin is a convincible treatment protocol for PID.

Seprafilm becomes brittle and sticky after contact with water, rendering it difficult to use in laparoscopic surgery. Hence, Seprafilm is not used frequently in laparoscopic surgery. This prospective randomized controlled trial aimed to compare the feasibility of two methods of application of Seprafilm: wet and non-wet. Two groups comprised 30 patients, each with 180 pieces of Seprafilm. Symptomatic patients who underwent laparoscopic surgeries, including hysterectomy and adnexal surgeries, were recruited. Successful application of Seprafilm was defined as a smooth attachment to the site of application. Sticky and fractured Seprafilm sheets were defined as failed applications. Between March 2016 and December 2017, 60 patients underwent laparoscopic Seprafilm placement. The preparation time was 32.67 ± 16.63 and 79.50 ± 22.01 s in the non-wet and wet groups, respectively (p &lt, 0.00). The success rate of application was 95.4% in the non-wet group and 98.3% in the wet group (p = 0.09). Placement time was 599.50 ± 90.18 s and 592.53 ± 105.82 s in the non-wet and wet groups, respectively (p = 0.25). In conclusion, the wet and non-wet application methods of Seprafilm were feasible in laparoscopic surgeries. The preparation time was different between the two groups. However, the rate of successful application and placement time was not different between the two groups.

Osteoarthritis (OA), the most common type of arthritis, causes pain in joints and disability. Due to the absence of ideal effective medication, stem cell transplantation emerges as a new hope for OA therapy. This study is aimed at evaluating the capability of human umbilical cord mesenchymal stromal cells (HUCMSCs) mixed with hyaluronan (HA) to treat osteoarthritis in a rabbit model. Differentiation capability of HUCMSCs, magnetic resonance image examination, and immunohistochemistry of the cartilage after transplantation of HUCMSCs mixed with HA in a rabbit OA model were explored. HUCMSCs exhibited typical mesenchymal stromal cell (MSC) characteristics, including spindle-shaped morphology, surface marker expressions (positive for human leukocyte antigen- (HLA-) ABC, CD44, CD73, CD90, and CD105; negative for HLA-DR, CD34, and CD45), and trilineage differentiation (chondrogenesis, adipogenesis, and osteogenesis). The gene expression of SOX9, type II collagen, and aggrecan in the HUCMSC-derived chondrocytes mixed with HA was increased after in vitro chondrogenesis compared with HUCMSCs. A gross and histological significant improvement in hyaline cartilage destruction after HUCMSCs mixed with HA was noted in the animal model compared to the OA knees. The International Cartilage Repair Society histological score and Safranin O staining were significantly higher for the treated knees than the control knees ( p < 0.05 ). Moreover, the expression of MMP13 was significantly decreased in the treated knees than in the OA knees. In conclusion, HUCMSCs mixed with HA in vitro and in vivo might attenuate the cartilage destruction in osteoarthritis. Our study provided evidence for future clinical trials.

BACKGROUND Hormonal fluctuations may trigger the onset of bipolar disorder. We designed a longitudinal follow-up study to evaluate the association between hysterectomies and bipolar disorder risk. METHODS We conducted a large retrospective cohort study using Taiwan's National Health Insurance Research Database. A total of 4,337 women aged 30 to 50 years who underwent the hysterectomy during 2000-2013 were selected and 17,348 patients without hysterectomy were selected for comparison (1:4 match). Poisson regression analysis was used to calculate the incidence rate ratio (IRR) and 95% confidence interval (CI). RESULTS During the follow-up of 7.93 years, 20 participants with hysterectomy and 28 without hysterectomy developed bipolar disorder. Receiving hysterectomy was associated with the risk of developing bipolar disorder (adjusted IRR = 2.80; 95% CI = 2.54-3.09). Women with hysterectomy had a higher risk of bipolar disorder in follow-up durations of

This study aimed to evaluate the risk of ischemic stroke (IS) in hormone therapy (HT) with oral conjugated equine estrogen (CEE) and estradiol (E2) in postmenopausal women in Taiwan. A retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database, a population-based healthcare claims dataset. Eligible women, aged 40–65 years, who received HT with E2 and CEE orally were enrolled. The primary outcome was IS. Propensity score matching with menopausal age and comorbidities was used. Cox proportional hazard regression models were used to calculate the incidence and hazard ratios (HRs) for IS. The mean menopausal ages of the E2 and CEE groups were 50.31 ± 4.99 and 50.45 ± 5.31 years, respectively. After adjusting for age and comorbidities, the incidence of IS was 1.17-fold higher in the women treated with CEE than in those treated with E2 (4.24 vs. 3.61/1000 person-years), with an adjusted HR (aHR) of 1.23 (95% confidence interval [CI] 1.05–1.44). Moreover, HT with CEE initiated within 5 years of menopause had a higher HR than E2 (aHR = 1.20; 95% CI 1.02–1.42). In conclusion, HT with oral CEE might be associated with a higher risk of IS than E2 in postmenopausal Taiwanese women. The use of HT with CEE should be cautioned with the risk of IS.

The aim of this study was to compare the clinical outcomes of transvaginal mesh (TVM) surgery with and without midline fascial plication for anterior prolapse repair. This is a prospective randomized trial in a teaching hospital. This study compared patients with anterior vaginal wall prolapse (POP-Q Ba &gt, −1) who were randomly assigned to either transvaginal mesh (TVM, Avaulta SoloTM, CR Bard. Inc., Covington, GA, USA polypropylene mesh delivery system) (group A, n = 32) or TVM with concomitant midline fascial plication (group B, n = 32). The outcomes of anatomy correction and life quality were evaluated using a pelvic organ prolapse quantification system and questionnaires. Sixty-four patients were included from January 2011 through April 2014 in this study. Group A had a mean age of 63.7 years and a body mass index (BMI) of 25.4 kg/m2. Group B had a mean age of 62.9 years and a BMI of 25.4. The mean follow-up duration was 18.6 months (range 12–50). At the 12-month follow-up, anatomic recurrence was higher in Group A (5/31, 16.1%) than in Group B (1/30, 3.3%) but without statistical significance (p = 0.19). Improvements in symptoms and quality of life were not significantly different between the two groups. Mesh extrusion was detected in three of 61 patients (4.9%): two from group A (6.7%) and one from Group B (3.2%). TVM with concomitant midline fascia repair for anterior vaginal prolapse had a comparable anterior support and mesh exposure rate compared with TVM alone. Trial Registration: IRB-B09904021

BACKGROUND Hysteroscopy is a traditional diagnostic method, whereas vaginoscopy is a more recent but proven approach. However, most physicians are unfamiliar with vaginoscopy. We aimed to compare the feasibility and tolerability between the two techniques to increase clinical awareness. METHODS We retrospectively reviewed the data of 100 patients who underwent office hysteroscopy with either the standard approach or the vaginoscopic approach between May and July 2019. While the standard hysteroscopy group underwent speculum insertion and the cervix was grasped with forceps, the vaginoscopy group did not. The primary outcome was a successfully completed examination. Related outcomes were the pain score, complications, and absence of signs of infection at 1 week after completing the examination. RESULTS The success rates of vaginoscopy and standard hysteroscopy were comparable (95.5% vs 96.3%). The median time to complete a vaginoscopy (135 seconds) was significantly shorter than to complete a standard hysteroscopy (190 seconds, p = 0.02). The median pain score was 3 for vaginoscopy, which was significantly lower than that for standard hysteroscopy (5; p = 0.01). There were no differences in the surgical complication rate between vaginoscopy (n = 4) and standard hysteroscopy (n = 3) (relative risk = 0.81, 95% confidence interval = 0.11-6.00). CONCLUSION Vaginoscopy required a shorter time for the completion of the examination and involved lesser pain than the standard hysteroscopy. The success rates were comparable between the two techniques. Therefore, vaginoscopy is a good option for office hysteroscopic examinations.

Epithelial ovarian cancer (EOC) is a heterogeneous disease with a variety of distinct clinical and molecular characteristics. The currently available and common research models for EOC include tumor cell lines and patient-derived xenografts. However, these models have certain shortcomings: establishing a cell line is time-consuming, loss of genetic traits after long-term culture is a possibility, and investment is required in terms of animal care facilities. Therefore, better research models are required. Organoid technology was originally developed from colorectal cancer. Tumor organoid is a three-dimensional culture system and can help accurately recapture the tumor phenotype from the original tumor. Tumor organoid systems can overcome the above-mentioned shortcomings of the currently available research models. The organoid model can be used for culturing ovarian cancer subtypes, screening drugs, assessing genomes, and establishing biobanks. However, the currently available organoid models can only culture one type of cells, epithelial cells. Therefore, an organoid-on-a-chip device can be developed in the future to provide a microenvironment for cell-cell, cell-matrix, and cell-media interactions. Thus, organoid models can be used in ovarian cancer research and can generate a simulated

The association between bladder antimuscarinic use and dementia development is unclear. We used data from the Taiwan National Health Insurance Research Database to determine the association between the exposure dose and duration of bladder antimuscarinics and the subsequent dementia risk. We enrolled participants aged 55 years or more and defined a dementia cohort (International Classification of Diseases, Ninth Revision, Clinical Modification codes 290, 294.1, and 331.0). We used a propensity score matching method, and randomly enrolled two controls without dementia. We evaluated dementia risk with respect to the exposure dose and duration of treatment with seven bladder antimuscarinics (oxybutynin, propiverine, tolterodine, solifenacin, trospium, darifenacin, and fesoterodine) used for at least 1 year before the index date, after adjusting for age, sex, comorbidities, and medications. The dementia risk was 2.46-fold (95% confidence interval: 2.22–2.73) higher in Taiwanese patients who used bladder antimuscarinics for ≥ 1 year than in those who were not exposed to this treatment. The risk proportionally increased with increasing doses of antimuscarinics for less than 4 years. Taiwanese patients aged 55 years or more on bladder antimuscarinics exhibited a higher risk of dementia. Additional studies in other countries are required to determine whether this result is valid worldwide.

Mesenchymal stem cell (MSC) therapy has been investigated intensively for many years. However, there is a potential risk related to MSC applications in various cell niches. Methods: The safety of intravitreal MSC application and the efficacy of MSC-derived conditioned medium (MDCM) were evaluated in the normal eye and the diseased eye, respectively. For safety evaluation, the fundus morphology, visual function, retinal function, and histological changes of the retina were examined. For efficacy evaluation, the MDCM was intravitreally administrated in a rodent model of anterior ischemic optic neuropathy (rAION). The visual function, retinal ganglion cell (RGC) density, and neuroinflammation were evaluated at day 28 post-optic nerve (ON) infarct. Results: The fundus imaging showed that MSC transplantation induced retinal distortion and venous congestion. The visual function, retinal function, and RGC density were significantly decreased in MSC-treated eyes. MSC transplantation induced astrogliosis, microgliosis, and macrophage infiltration in the retina due to an increase in the HLA-DR-positive MSC proportion in vitreous. Treatment with the MDCM preserved the visual function and RGC density in rAION via inhibition of macrophage infiltration and RGC apoptosis. Conclusions: The vitreous induced the HLA-DR expression in the MSCs to cause retinal inflammation and retina injury. However, the MDCM provided the neuroprotective effects in rAION.

The effect of hysterectomy on vesicourethral functions remains controversial. The objective of this study was to examine the association between hysterectomy and de novo lower urinary tract symptoms (LUTSs). We identified 8514 patients who had undergone hysterectomy between January 1, 2000, and December 31, 2012, from Taiwan’s National Health Insurance (NHI) Research Database. A control cohort, comprising 34,056 age-matched patients who had not undergone hysterectomy, was created for comparison. All hysterectomy and control patients were followed up until diagnosis as having LUTSs (dysuria, urinary retention, incontinence, and increased urinary frequency and urgency), withdrawal from the NHI system, death, or December 31, 2013. Patients were excluded if LUTSs were diagnosed before or at the time of hysterectomy. The adjusted hazard ratio (aHR) of subsequent de novo LUTSs was higher in the hysterectomy patients [1.57, 95% confidence interval (CI) 1.46–1.70] than in the controls during the follow-up period. Compared with the controls, the highest risk of de novo LUTSs was noted in patients who had undergone vaginal hysterectomy (VH; aHR 1.89, 95% CI 1.57–2.28) followed by those who had undergone laparoscopy-assisted VH (LAVH; aHR 1.74, 95% CI 1.56–1.94). We found that undergoing hysterectomy was associated with increased risks of developing lower urinary tract symptoms in women. This association was more pronounced for women undergoing the vaginal or laparoscopically assisted hysterectomy. Further large-scale prospective studies or clinical trials are needed to explore whether causality exists.

Stroke can cause death and disability, resulting in a huge burden on society. Parkinson’s disease (PD) is a chronic neurodegenerative disorder characterized by motor dysfunction. Osteoarthritis (OA) is a progressive degenerative joint disease characterized by cartilage destruction and osteophyte formation in the joints. Stem cell therapy may provide a biological treatment alternative to traditional pharmacological therapy. Mesenchymal stem cells (MSCs) are preferred because of their differentiation ability and possible derivation from many adult tissues. In addition, the paracrine effects of MSCs play crucial anti-inflammatory and immunosuppressive roles in immune cells. Extracellular vesicles (EVs) are vital mediators of cell-to-cell communication. Exosomes contain various molecules such as microRNA (miRNA), which mediates biological functions through gene regulation. Therefore, exosomes carrying miRNA or other molecules can enhance the therapeutic effects of MSC transplantation. MSC-derived exosomes have been investigated in various animal models representing stroke, PD, and OA. Exosomes are a subtype of EVs. This review article focuses on the mechanism and therapeutic potential of MSC-derived exosomes in stroke, PD, and OA in basic and clinical aspects.

// Dah-Ching Ding 1, 2 , I-Ju Tsai 3, 4 , Jen-Hung Wang 5 , Shinn-Zong Lin 6 and Fung-Chang Sung 3, 7 1 Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan 2 Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan 3 Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan 4 College of Medicine, China Medical University, Taichung, Taiwan 5 Department of Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan 6 Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan 7 Department of Health Services Administration, China Medical University, Taichung, Taiwan Correspondence to: Dah-Ching Ding, email: dah1003@yahoo.com.tw Fung-Chang Sung, email: fcsung1008@yahoo.com Keywords: cardiovascular disease; coronary artery disease; diabetes mellitus; hypertension; polycystic ovary syndrome Received: August 02, 2017 Accepted: November 16, 2017 Published: January 04, 2018 ABSTRACT Women with polycystic ovary syndrome are characterized by obesity, menstruation irregularity, hirsutism and infertility, and prevalent with cardiometabolic comorbidities, but population-based studies on the risk of developing coronary artery disease are limited. From claims data of the Taiwan National Health Insurance, we identified 8048 women with polycystic ovary syndrome aged 15-49 years newly diagnosed in 1998-2013, and 32192 women without the syndrome and CAD as controls, frequency matched by age and diagnosis date. By the end of 2013, after a mean follow-up period of 5.9 years, the overall incidence of coronary artery disease was 63% higher in women with polycystic ovary syndrome than in controls (2.25 vs. 1.38 per 1000 person-years). The adjusted hazard ratio [aHR] of coronary artery disease was 1.44 (95% confidence interval (CI) = 1.14–1.81) for women with polycystic ovary syndrome, compared with controls. Hazards of coronary artery disease were significant during follow-up periods of 3-4 years (aHR = 1.52, 95% CI = 1.00–2.30) and of 5–9 years (aHR = 1.58, 95% CI = 1.07–2.32). The incidence of coronary artery disease increased further in those with cardiometabolic comorbidities. Among women with polycystic ovary syndrome, those with comorbid diabetes had an incidence of 35.2 per 1000 person-years, 20-fold greater than those without cardiometabolic comorbidities. In conclusion, women with polycystic ovary syndrome are at an elevated risk of coronary artery disease. Preventive interventions should be provided to them, particularly for those with the comorbidity of metabolism symptom.

Primitive neuroectodermal tumors (PNETs) are rare malignant tumors and extremely rare in uterine corpus. We report a case of primary uterine PNET in Taiwan. A 68-year-old woman presented with vaginal bleeding and abdominal fullness for 2 weeks. Computed tomography revealed one 8.0 cm uterine corpus tumor with carcinomatosis peritonei and ascites. The cancer antigen 125 level was high (280.7 IU/ml). Pathology of endometrial biopsy diagnosed PNET according to the characteristic of small blue round cells with Homer-Wright rosettes and Friend leukemia integration 1 transcription factor (FLI-1) positive. She received dose-dense chemotherapy with paclitaxel and carboplatin, but the response was poor and the PENT metastasized to liver. PNETs belong to small blue round cell tumor group that is difficult to be diagnosed on histopathology. The immunohistochemistry for CD99 and FLI-1 provides high sensitivity and specificity for diagnosis, respectively. No optimal treatment is established due to rarity. The prognosis is poor, usually

Teratoma of the ovary is the most frequently encountered germ cell tumor. It usually occurs in young women. Gliomatosis peritonei (GP) is mature neural glial tissue implanted onto the peritoneal surface. We present a case of a mature teratoma accompanied by GP and massive ascites in postmenopausal women. A 54-year-old, G0P0, woman presented in the gynecology outpatient department with abdominal distension for 6 months. Computed tomography scan of the abdomen and pelvis displayed an ovarian mass about 20 cm × 18 cm with peritoneal seeding, ascites, and enlarged paraaortic lymph nodes. A total hysterectomy and bilateral adnexectomy were performed. The pathology showed the left ovary contained a dermoid cyst. The biopsy of the peritoneal nodule displayed glial tissue confirming the diagnosis of GP. The patient remained in good condition 6 months postoperatively. We suggest GP be considered in patients presenting with teratomas and massive ascites. The radiological diagnosis is challenging due to the rarity of GP. Continued follow-up of patients with teratomas and GP is mandatory due to the potential of malignant transformation.

Objectives Most research into the management of pelvic inflammatory disease (PID) is in younger women and focuses on sexually transmitted pathogens such as N. gonorrhoeae or C. trachomatis. Non-sexually transmitted bacterial pathogens and PID in older women are rarely examined. The objective of this study is to explore cervical culture pathogens in women of different age groups in a medical center in eastern Taiwan. Methods We enrolled patients whose medical records were diagnosed with PID (ICD-9-CM 614.0 [N70.01–03], 614.1[N70.11–13], 614.9 [N73.5, N73.9]) at our hospital from October 2014 to March 2020. Patients were divided into three groups according to age: the age Results A total of 96 patients were included in the study. There were 31 patients in the age ≥ 45 years group, 52 patients in the age 25–44 years group, and 13 patients in the age Prevotella bivia was more common in the age Conclusions This may be due to different pathogeneses of PID in the age ≥ 45 years patients. Our study can be used as a reference for antibiotic choice of non-sexually transmitted PID and to prevent long-term sequelae of PID.

We briefly share our experience of using the silent mentor program in the Medical Simulation Center (MSC) of Tzu Chi University (TCU), Hualien, Taiwan, to improve our minimally invasive surgical level and patient's safety. The silent mentor program, established in 2000 by the Department of Anatomy of TCU, is a pioneering clinical skill training program based on unembalmed bodies. This program provides three valuable advantages for surgery. The first is the comprehensive understanding of the deep or rarely observed but crucial structures of the human body, which is normally difficult to achieve in living humans. The second is gaining the first experience of a novel procedure or surgery on silent mentors rather than on living humans, which is essential for young surgeons to begin their careers. The third is evaluating the safety and feasibility of a novel surgical method. In addition to surgical techniques, the most valuable point of the program is the humane ceremonies conducted for silent mentors to nourish our soul. After the workshop, all the incision wounds on every silent mentor were carefully checked and sutured in the same manner as in closing surgical wounds in a patient. Subsequently, encoffining, cremation, and thanksgiving ceremonies were solemnly held, in the hope that the medical students or trainees would imperceptibly understand their responsibility to society and the silent mentor's expectations. The Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive Therapy, or the Taiwan Association for Minimally Gynecology Therapy, or both can consider initiating a regular silent mentor program in the MSC of TCU. It is not only intended to improve the skills of surgeons but also to allow them to participate in the interactive ceremony and thus refresh their humanitarian knowledge.

Objectives: The objective of this study is to report our initial experience with patients undergoing transvaginal natural orifice transluminal endoscopic surgery (NOTES). Materials and Methods: From September 2016 to December 2016, patients who were not virgins and did not have pelvic inflammation or obliteration of the cul-de-sac who underwent NOTES hysterectomy or ovarian cystectomy (OC) were included in the study. Results: Transvaginal NOTES was performed smoothly in six patients, two patients (mean age 35 years, mean body mass index [BMI] 25) received an OC and four patients (mean age 49 years, mean BMI 27) underwent a hysterectomy. One patient with a hysterectomy received concurrent adhesiolysis. The mean surgical times were 74 and 75 min and blood loss was 50 and 87.5 ml in the OC and hysterectomy groups, respectively. One patient with a hysterectomy had a postoperative fever with 38°C last for 2 days. Pain scores were 0 at 48 h postoperatively in both groups. Conclusion: Transvaginal NOTES is a feasible and safe technique for hysterectomy and OC in our patients and those in previous reports. This procedure was minimally invasive with no scars on the abdomen as well as little pain.

During second-look surgery or hospitalization, intra-abdominal surgeries may cause severe postoperative complications, such as pelvic adhesion, postoperative ileus, and severe pain. However, only few studies have analyzed the outcomes of antiadhesive barriers in second-look surgery. This retrospective study aims to identify the outcomes of different antiadhesive barriers by analyzing surgical images. The study included patients who received an adhesion barrier during second-look surgery between January 2011 and November 2017. Four brands of adhesive barriers were used: Interceed, Seprafilm, Adept, and SurgiWrap. Adhesion scores were calculated for four quadrants of the uterus and surrounding structures before and after the use of antiadhesive barriers. The differences between the data of 2 observers and surgery times were also determined. A total of 18 patients were enrolled in the study. The adhesion scores were not significantly different before and after the placement of antiadhesive barriers. The difference in the adhesion scores between the two observers was also not significant, except in the Seprafilm group (P = .029). Furthermore, no significant change in the adhesion scores was observed between the first and second surgeries. Therefore, using adhesion barriers may not decrease the adhesion scores in the current setting.

Hydrosalpinx in reproductive-age women without sexual experience is uncommon and may be asymptomatic. Hydrosalpinx-induced torsion of the adnexa is a rare situation and requires prompt and accurate management. This report describes a 21-year-old female without history of sexual intercourse presented with right lower abdominal pain. Ultrasonography revealed right ovary about 4.2 cm × 3.6 cm in size with a well-defined, round cystic mass measuring 6.3 cm × 4.1 cm without septations. Diagnostic laparoscopic surgery showed a darkish right ovary and round-shaped cystic right hydrosalpinx that twisted at the infundibulopelvic ligament. Laparoscopic detorsion and salpingostomy were performed successfully. This case is a rare gynecologic situation with hydrosalpinx induced adnexa torsion, making it a rare presentation. Early diagnosis is important for preventing ovarian gangrene. Laparoscopy is a useful tool for diagnosing and treating tubal and ovarian torsion. It brings good prognosis if detorsion was performed within 24 h.

We report a case with retained products of conception (RPOC) managed by hysteroscopic resection. A 45-year-old woman, G5P3SA1AA1, experienced spontaneous abortion on March 8, 2017, and had persistent vaginal bleeding since then. On May 12, 2017, she came to emergency room where endometrium biopsy was done and revealed degenerative gestational tissue with acute inflammation. On May 23, 2017, she followed up at outpatient department where ultrasonography showed no obvious intrauterine abnormalities with endometrial thickness of 6.5 mm. Office hysteroscopy was arranged and RPOC at the posterior uterine wall was suspected. She received hysteroscopic transcervical resection (TCR) of RPOC on May 26, 2017. After TCR, the vaginal bleeding discontinued. The pathology showed degenerative gestational products with acute inflammation. In conclusion, hysteroscopic TCR might be safe and feasible for RPOC.

OBJECTIVE To assess the safety and efficacy of contained manual morcellation (CMM) with a tissue pouch during minimally invasive robotic or laparoscopic surgeries. METHODS A retrospective cohort study included women who underwent robotic or laparoendoscopic single-site surgery at a tertiary referral center between February 2014 and April 2017. The specimen was postoperatively contained, sliced into one or more long strips, and then pulled out. The surgical type, specimen containment time, containment failure rate, specimen weight, manual morcellation time, and overall CMM speed (g/min) were recorded. Surgical complications related (bowel or bladder injury, ureteral injury, vascular injuries, and tumor dissemination) or not related (delayed wound healing, infection, and hernia) to CMM were also documented. The patients were followed up for 2 years. RESULTS A total of 165 cases were recorded, comprising 149 cases that underwent laparoscopic and 16 that underwent robotic gynecological surgeries. The average time for specimen containment and manual morcellation in CMM was 6.7 ± 5.0 and 13.2 ± 11.2 min, respectively. The mean morcellation speed was 25.1 ± 8.5 g/min. Among the specimens, those of the uterus with adenomyosis had the lowest CMM speed (21.4 ± 8.0 g/min), whereas those of the uterus with myoma had the highest speed (27.5 ± 8.9 g/min). The pouch perforation rate after CMM was 13.3% and no pouch-related complication was noted. CONCLUSION CMM is an efficient method for specimen removal.

Vitamin D deficiency is common globally with a higher prevalence in women, especially during pregnancy. Among the pregnant women, Vitamin D deficiency was reported up to 80% in the Asian group. Vitamin D deficiency was related to a higher risk of maternal complications including preeclampsia, impaired glucose tolerance, and cesarean section rate, and neonatal complications including low birthweight, neonatal hypocalcemia seizure, and impaired skeletal, lung and immune development. There were no data supporting Vitamin D deficiency screening routinely in pregnancy regarding cost-effectiveness or health benefits. The measurement of Vitamin D in the high-risk group of women is necessary. Subsequent supplement with Vitamin D with and without calcium supplement during pregnancy had been statistically significantly reported to decrease the risk of preeclampsia, preterm birth, and low birth body weight. However, due to a lack of studies, the strategies of dietary and nutritional supplement for fetal growth restriction prevention are not statistically effective and are not yet recommended. The present review is to provide an overview of the clinical and the experimental evidence of Vitamin D deficiency-related complication and review of available options for the prevention and management of these complications.

STUDY QUESTION Is polycystic ovarian syndrome (PCOS) in women associated with the increasing incidence of depression in an East Asian population? SUMMARY ANSWER Younger PCOS patients (aged 15–29 years), but not middle-aged patients, have an increased risk of depression in Taiwan. WHAT IS KNOWN ALREADY During reproductive age, 6–10% of women have PCOS. Among them, ~40% experience depression, mostly at young ages. STUDY DESIGN, SIZE, DURATION This is a retrospective population-based cohort study analysing depression risk in Taiwanese women using data from a nationwide database containing 1998–2013 data of nearly 1 million people. PARTICIPANTS/MATERIALS, SETTING, METHODS We included 15- to 50-year-old women newly diagnosed with PCOS during 1998–2013 from the Taiwan National Health Insurance Research Database as the PCOS cohort (n = 7684) and then randomly matched them 4 : 1 by sex, age and index year with women without PCOS as the comparison cohort (n = 30 736). We used multivariable Cox proportional hazard regression analysis to determine the association between PCOS and depression risk [hazard ratio (HR) with 95% confidence interval (CI)]. MAIN RESULTS AND THE ROLE OF CHANCE The incidence of depression was higher in the PCOS group than in the comparison group (6.67 vs. 4.82 per 1000 person-years; adjusted HR = 1.28, 95% CI = 1.12–1.46). PCOS patients aged 15–29 years had a significantly higher depression risk (adjusted HR = 1.39, 95% CI = 1.18–1.65); no such significant association was noted among patients aged 30–39 years and 40–50 years. LIMITATIONS, REASONS FOR CAUTION A history of malignancy, which may increase depression, could not be obtained for our study patients. Moreover, we could not obtain a family history of depression, a relevant risk factor for depression. Finally, the database has no records of body mass index, which may influence depression outcome. WIDER IMPLICATIONS OF THE FINDINGS In Taiwan, younger PCOS patients (15–29 years), but not the middle-aged patients, have an increased risk of depression. Our findings provide vital information to patients, clinicians, the Taiwan Government and other developing Asian countries to improve the PCOS treatment strategies in the future. Routine screening for depression in PCOS patients may be implemented into the health practice. STUDY FUNDING/COMPETING INTEREST(S) This study was supported in part by the Taiwan Ministry of Health and Welfare Clinical Trial Center (MOHW108-TDU-B-212-133 004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 107-2321-B-039 -004-), Tseng-Lien Lin Foundation, Taichung, Taiwan and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. No competing interest existed. TRIAL REGISTRATION NUMBER N/A.

Rationale: Vesicovaginal fistula (VVF) most commonly occurs due to iatrogenic injury during surgery or obstructed labor. We report a rare case of a patient with severe pelvic organ prolapse who developed VVF even though pessary had not been used.

Rationale We report a case with inguinal subcutaneous endometriosis without typical cyclic dysmenorrhea and accompanied with a hernia sac treated with resection of the tumor and herniorrhaphy. Patient concerns A 40-year-old woman had a painless enlarged inguinal nodule for 3 months. Diagnoses Subcutaneous endometriosis accompanied with a hernia sac. Interventions Ultrasonography showed a hypoechoic lesion (3.0 cm × 2.0 cm), and an inguinal subcutaneous tumor was first suspected. After surgical exploration, a cystic lesion was excised and the hernia hole was repaired by herniorrhaphy. The immunohistochemical analysis of the small endometriotic cyst-like lesion revealed calretinin (-) in epithelial cells and CD10 (+) in stromal cells, indicative of subcutaneous endometriosis accompanied with a hernia sac. Outcomes The patient was followed up for 1 year and without recurrence. Lessons Cutaneous endometriosis accompanied with a hernia sac can be presented without typical endometriosis-associated symptoms such as dysmenorrhea. Inguinal endometriosis might be the differential diagnosis of inguinal painless nodules.

Aim Lower urinary tract symptoms (LUTS) result in morbidities; however, their association with the occurrence of hip fracture is relatively unknown in the context of Asian studies. The purpose of the study was to investigate this link with the hip fracture risk in Taiwanese men and women aged 50 years and above. Materials and methods From 2000 through 2012, a population-based retrospective cohort study was conducted; claims data of 18,976 patients diagnosed with LUTS (dysuria, urinary retention, incontinence, and increased urinary frequency and urgency) were retrieved from Taiwan’s National Health Insurance Research Database. The patients were compared with 1:2 age, sex, and index year-matched controls (comparison group, n = 37,952). The incidence and hazard ratios of the hip fracture risk were calculated by the Cox proportional hazard regression models. Results The mean age was 66.2 ± 9.7 years, and the proportion of men was 58.1% in both study groups. Fractures occurred in 772 patients and 1,156 control subjects. The corresponding incidences were 7.0 and 5.0/1000 person-years. Compared to the control subjects, the patients with LUTS had an increased hip fracture risk [adjusted hazard ratio (aHR) = 1.29; 95% confidence interval (CI): 1.17–1.42]. LUTS was independently associated with an increased hip fracture risk in both men (aHR = 1.24; 95% CI: 1.08–1.42) and women (aHR = 1.34; 95% CI: 1.18–1.53) (p for interaction = 0.557). Similarly, the subgroup effect of age on hip fracture risks was not found (p for interaction = 0.665). Conclusion The study found LUTS was associated with an increased risk of hip fracture. Large-scale prospective studies in diverse populations are required to investigate causalities.

Objective: The workload of obstetric and gynecologic (OB-GYN) physicians has been an unprecedented increase because of the decrease in the number of such physicians. This study aimed to demonstrate that the hospitalist mode was the best mode for the work-life balance of OB-GYN physicians. Materials and Methods: This was a retrospective study in a tertiary academic hospital. Patients were admitted to the labor ward for delivery. The number of deliveries performed by each OB-GYN physician in different working modes was measured. We reviewed the medical charts of women admitted for delivery as well as the shift schedule of OB-GYN physicians from January 1, 2018, to June 30, 2018. We classified deliveries into three modes: the traditional mode (patient designation), on-call mode, and the hospitalist mode. Traditional mode was the work mode currently. On-call mode and the hospitalist mode were simulated conditions. The number of deliveries and the total OB-GYN physician worked time for their shift were recorded. The differences between the three modes and between OB-GYN physicians were assessed using analysis of variance. Results: In total, 237 deliveries were recorded over 6 months (3 deliveries were excluded from our data); these deliveries were performed by four OB-GYN physicians named A to D. Significant differences in workload were noted between OB-GYN physicians working in the traditional mode and those in the on-call mode, but no significant differences were noted among those working in the hospitalist mode. All OB-GYN physicians worked an average of seven shifts, and no significant differences among them were noted. Conclusion: The hospitalist mode might be the optimal mode for OB-GYN physicians to achieve a favorable work-life balance if their original main jobs are obstetric practice.

In both normal and tumor tissues, receptor tyrosine kinases (RTKs) may be pleiotropically expressed. The RTKs not only regulate ordinary cellular processes, including proliferation, survival, adhesion, and migration, but also have a critical role in the development of many types of cancer. The Tyro3, Axl, and MerTK (TAM) family of RTKs (Tyro3, Axl, and MerTK) plays a pleiotropic role in phagocytosis, inflammation, and normal cellular processes. In this article, we highlight the cellular activities of TAM receptors and discuss their roles in cancer and immune cells. We also discuss cancer therapies that target TAM receptors. Further research is needed to elucidate the function of TAM receptors in immune cells toward the development of new targeted immunotherapies for cancer.

This work proposes a modified method for removing the uterine body in laparoendoscopic single-site subtotal hysterectomy based on the principle of “contain before transection, and contain before manual morcellation,” using a surgical tissue pouch (LapSac, Cook Inc., Bloomington, IN, USA). The main advantage of this method is a low likelihood of a bag rupture during manual morcellation which minimizes the potential risk of iatrogenic parasitic myoma and/or cancer cell dissemination. This method also benefits from lower cost, less surgical time, and “containing before transection” makes the shifting of uterine specimens in the laparoendoscopic single-site more feasible. The limitations of this method, and potential means of overcoming them, are also discussed. Potentially, this method of “contain before transection, contain before manual morcellation” can be applied to other organ tissue removal in laparoscopic surgeries but more cases must be studied to confirm its safety and feasibility.

In pregnancy, the most frequently discovered ovarian tumor is mature cystic teratomas. Acute ovarian torsion in a pregnant patient is rare and is difficult to diagnose. Recent studies have demonstrated that laparoscopy during pregnancy is safe and confers many advantages over laparotomy. We report a patient with acute ovarian teratoma torsion treated with ovarian cystectomy via a single-port laparoscopy and review of the literature. A 17-year-old woman, gravida 1, in her 12 th week of pregnancy, came to our emergency room with severe abdominal pain and nausea. Torsion of ovarian teratoma (5 cm in diameter) was suspected. The patient underwent emergent laparoendoscopic single-site surgery (LESS) under general anesthesia, and the detorsed cyst was successfully excised and removed intact through the single port. This was enabled by the endobag technique, thus preventing spillage of the cyst content into the abdominal cavity. The fetus tolerated surgery well without complications and was term delivered uneventfully. The literature review revealed that the advantages of using LESS in pregnant patients are that this technology is safe for both the mother and the fetus, and it allows easy removal of specimen. However, it also has several drawbacks: technically challenging and limitation of working space. In conclusion, LESS seems to be a viable alternative to multiport laparoscopic surgery for the treatment of adnexal masses in pregnancy.

Objective To report a case of small bowel obstruction caused by barbed suture applied in hysterosacropexy, and possible solutions. Case Report A 57-year-old woman underwent laparoscopic hysterosacropexy for a Stage 2 uterine prolapse, presenting with acute abdominal pain and a bowel obstruction syndrome 2 days following the surgery. Conservative treatment was given, but the symptoms did not improve and gradually became worse. Diagnostic laparoscopy was performed on the 7th day after the hysterosacropexy, and the volvulus was found. The residual end of the barbed V-Loc adopted in the peritoneal closure was incidentally hooked to the mesentery and caused small bowel obstruction. The redundant V-Loc was released and cut off at 2 cm. Neither bowel ischemia nor significant bowel injury was noted. Two days later, she was discharged without complication. Conclusion A barbed suture has a risk of bowel obstruction when used in surgery. To avoid a grave prognosis, early diagnosis and prompt management of complication is necessary.

Aim This study investigated the risk of osteoporosis or bone fractures (vertebrae, hip and others) in hysterectomized women in Taiwan. Materials and methods This is a retrospective population-based cohort study from 2000 to 2013. Women aged ≥30 years who underwent hysterectomy between 2000 and 2012 were included in this study. The comparison group was randomly selected from the database with a 1:4 matching with age and index year. Incidence rate and hazard ratios of osteoporosis and bone fracture between hysterectomized women and the comparison group were calculated. Cox proportional hazard regressions were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Results We identified 9,189 hysterectomized women and 33,942 age-matched women without a hysterectomy. All women were followed for a median time of about 7 years. The adjusted hazard ratio (aHR) of subsequent osteoporosis or bone fracture was higher in the hysterectomy women (2.26, 95% confidence interval [CI] = 2.09–2.44) than in the comparison group. In the subgroup analysis, oophorectomy and estrogen therapy increase the risk of osteoporosis or fracture in both groups. Regarding the fracture site, the aHR of vertebral fracture (4.92, 95% CI = 3.78–6.40) was higher in the hysterectomized women than in the comparison group. As follow-up time increasing, the aHR of vertebral fracture in hysterectomized women were 4.33 (95% CI = 2.99–6.28), 3.89 (95% CI = 2.60–5.82) and 5.42 (95% CI = 2.66–11.01) for Conclusions In conclusion, we found that hysterectomized women might be associated with increased risks of developing osteoporosis or bone fracture.

Aspirin (ASA) exerts an anti-tumor effect via the COX pathway. Clinical studies on the chemopreventive effects of ASA on uterine cancer (UC) remain inconsistent. We used population-based retrospective cohort study to evaluate the UC in ASA users in Taiwanese women. From insurance claims data, we identified 23,342 women received ASA treatment between 2000 and 2010 and a comparison group of same sample size randomly selected from the same database matched by the propensity score. The incidence of UC in the ASA cohort was 10% of that in the comparison group (0.28 vs 2.73 per 10,000 person-years). The Poisson regression analysis estimated adjusted incidence rate ratio (IRR) was 0.10 (95% confidence interval (CI) = 0.09–0.11) for ASA users relatives to comparisons after controlling for covariates. The UC incidence in ASA users decreased with age, from 0.61 per 10,000 person-years in the 20 to 39 years old (adjusted IRR = 0.21, 95% CI = 0.15–0.29) to 0.21 per 10,000 person-years in the 65 to 80 years old (adjusted IRR = 0.15, 95% CI = 0.12–0.16). The incidence was higher in longer term users. Hormone therapy of estradiol was associated with the increase of UC risk in both cohorts, but less in ASA users than comparisons (1.34 vs 4.75 per 10,000 person-years). This study suggests that ASA use was associated with a decreased risk of UC. Further prospective randomized clinical trials are warranted to confirm the association.

Leiomyomas are the most common benign gynecologic tumors and the most common surgical indication for hysterectomy or myomectomy. Recurrent pelvic leiomyomas or vaginal leiomyomas are rare. We report the case of a 60-year-old woman with a history of a cesarean total hysterectomy 25 years before presenting to us, who developed a pelvic leiomyoma arising from the vaginal cuff. The patient underwent single-port laparoscopic tumor excision and recovered uneventfully.

Background Adnexal torsion is a gynecologic emergency that requires surgical treatment. In this study, we reviewed the surgical outcomes of women with adnexal torsion in eastern Taiwan (Hualien county, area 4,629 km2, 330,000 residents). Methods This retrospective study included 42 women diagnosed with surgically-proven adnexal torsion from January 1, 2010, to September 31, 2015. We compared the symptoms, objective findings, and surgical outcomes of patients who underwent laparotomy or laparoscopy. Results The laparoscopy and laparotomy groups included 27 and 15 patients, respectively. The most common symptom and sign was abdominal pain, followed by nausea and vomiting. In all patients, an adnexal tumor was detected through ultrasound. The median and range of time from admission to surgery was 1.5 (1–11.5) and 1.0 (1–11) hours in the laparotomy and laparoscopy groups, respectively. Compared with those undergoing laparotomy, the smaller tumor size [7 (4.2–10) vs. 10 (7–17) cm] and shorter hospital stay [4 (2–8) vs. 6 (3–9) days] in patients undergoing laparoscopy were significantly noted, respectively (P Discussion Acute onset of abdominal pain with a presenting ovarian tumor is the most common feature of adnexal torsion. Laparoscopic surgical group showed a small tumor size and a short ER hospital stay than laparotomy. Older age is the risk factor for radical surgery.

Polycystic ovary syndrome (PCOS) is a common endocrine disorder among the women of reproductive age. We conducted a nationwide population-based retrospective cohort study to analyze the association between PCOS and the subsequent development of gynecological cancers, namely endometrial, breast, and ovarian cancer. For this population-based cohort study, we used the Taiwan National Health Insurance Research Database, which contains information on approximately 24.7 million insured individuals. The cohort included women who had received a diagnosis of PCOS between 1998 and 2013. An age-matched systematic random-sampling method with a ratio of 1:4 was used for patient selection for the non-PCOS reference cohort. Multivariate Cox proportional hazard regression analysis was used to determine the effects of PCOS on the risks of gynecologic and breast cancer. The data are presented as hazard ratios (HRs) with 95% confidence intervals (CIs). The PCOS cohort consisted of 8155 patients with PCOS, and the comparison cohort consisted of 32,620 matched patients without PCOS. The incidence of endometrial cancer was 226 and 15 per 100,000 person-years in the PCOS and comparison groups, respectively. A statistically significant higher risk of endometrial cancer was found in the PCOS cohort (adjusted HR [aHR] = 17.7, 95% CI = 4.9–64.2) than in the comparison cohort. However, no association was observed between PCOS and ovarian (aHR = 1.64, 95% CI: 0.63–4.27) or breast cancer (aHR = 0.98, 95% CI: 0.58–1.65). The results of this large population-based cohort study supported the premise that women with PCOS might have an increased risk of endometrial cancer, but no association between PCOS and the risks of ovarian and breast cancer was found.

Background and Objectives: This study analyzed the trends of opportunistic salpingectomy (OS) accompanied by hysterectomy in a 9-year follow-up period at a single institute. Methods: This retrospective cohort study included 1184 women at Hualien Tzu Chi Hospital from 2007 to 2015 who underwent hysterectomy performed with or without OS. Parameters including patient age, operating time, surgical approach, length of hospital stay, and perioperative complications were evaluated. Results: There was an increase in the number of hysterectomies with OS (from 8% to 80%; P < .001) over the study period. Minimal additional operating time was necessary for hysterectomy with OS (3.7 and 3.6 minutes in open and laparoscopic surgery, respectively). No significant differences were observed in the risks of hospital readmission or blood transfusions between women who underwent hysterectomy with OS performed with the open approach and those who underwent the procedure using the laparoscopic approach. From 2007 to 2015, the proportion of open hysterectomies decreased from 56% to 6%. Conclusion: The results of this 9-year follow-up study revealed that, as a cancer prevention method, OS seems to be feasible and safe, requires minimal extra time, and does not increase the morbidity or long-term sequelae.

Hysterectomy and pelvic organ prolapse (POP) surgeries are two of the most common gynecologic surgeries conducted for benign conditions. This nationwide retrospective cohort study explored the risk of subsequent POP surgery following hysterectomy without simultaneous POP surgery. This study identified 7298 patients who underwent hysterectomy between January 1, 2000, and December 31, 2012, from the Taiwan National Health Insurance (NHI) Research Database. A comparison cohort was constructed comprising 29,192 age-matched patients who had not undergone hysterectomy. All hysterectomy and control patients were followed until they required POP surgery, withdrew from the NHI system, died, or December 31, 2012. Patients were excluded if they underwent POP surgery before or at the time of hysterectomy. The adjusted hazard ratio (aHR) of subsequent POP surgery in subjects with hysterectomy was higher [2.60, 95% confidence interval (CI) 1.79–3.78] than that of controls during the follow-up period. Compared with patients who had not undergone hysterectomy, the highest risks of subsequent POP surgery was noted in those who had undergone vaginal hysterectomy (VH; HR 6.29, 95% CI 1.54–25.79) followed by those who underwent laparoscopy-assisted VH (LAVH; HR 3.77, 95% CI 2.43–5.85). Hysterectomy may increase the risk of subsequent POP surgery, and various hysterectomy techniques, particularly VH and LAVH, may increase the risk of subsequent POP surgery.