Search

Brief exposure of monocytes to atherogenic molecules, such as oxidized lipoproteins, triggers a persistent pro-inflammatory phenotype, named trained immunity. In mice, transient high-fat diet leads to trained immunity, which aggravates atherogenesis. We hypothesized that a single high-fat challenge in humans induces trained immunity. In a randomized controlled cross-over study, 14 healthy individuals received a high-fat or reference shake, and blood was drawn before and after 1, 2, 4, 6, 24, and 72 h. Incubation of donor monocytes with the post-high-fat-shake serum induced trained immunity, regulated via Toll-like receptor 4. This was not mediated via triglyceride-rich lipoproteins, C12, 14, and 16, or metabolic endotoxemia. In vivo , however, the high-fat challenge did not affect monocyte phenotype and function. We conclude that a high-fat challenge leads to alterations in the serum composition that have the potential to induce trained immunity in vitro . However, this does not translate into a (persistent) hyperinflammatory monocyte phenotype in vivo ., Competing Interests: M.G.N. and L.A.B.J. are scientific founders of TTxD and Lemba Therapeutics., (© 2024 The Author(s).)

Background: We present a rare but serious complication of Essure microinsert sterilization., Study Design: Case report., Results: A 42-year-old woman presented with nausea, vomiting, abdominal pain and abdominal distension 1 month after uncomplicated Essure sterilization. Abdominal X-ray showed small bowel obstruction. At subsequent laparotomy, a stretched Essure device was found ensnaring the terminal ileum. It had caused strangulation and local perforation of the bowel wall. The device was removed and an ileocecal resection with side-to-side ileocolostomy was performed. In retrospect, the aberrant location of the right Essure device near the ileocecal junction was noticed on the abdominal X-ray., Conclusions: This case illustrates that perforation of an Essure device can result in a serious complication leading to ileocecal resection. An abdominal X-ray with specific attention to the correct location of the Essure coils is advisable for patients presenting with small bowel obstruction after Essure sterilization., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To determine the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) in early stage endometrial cancer alongside a multicenter randomised controlled trial (RCT)., Methods: An economic analysis was conducted in 279 patients (TLH n=185; TAH n=94) with early stage endometrial cancer from a societal perspective, including all relevant costs over a three month time horizon. Health outcomes were expressed in terms of major complication-free rate and in terms of utility based on women's response to the EQ-5D. Comparisons of costs per major complication-free patient gained and costs with utility gain and costs were made, using incremental cost effectiveness ratios., Results: The mean major complication-free rate and median utility scores were comparable between TLH and TAH at three months. TLH is more costly intraoperatively (Δ$1.129) and less costly postoperatively in-hospital (Δ$-1.350) compared to TAH. Incremental costs per major complication-free patient were $-52. Higher cost ($249) were generated while no gains in utility (-0.02) were observed for TLH compared to TAH. Analysing utility at six weeks, incremental costs per additional point on the EQ-5D scale were $1.617., Conclusion: TLH is cost effective compared to TAH, based on major complication-free rate as measure of effect. Along with future cost saving strategies in laparoscopy, TLH is assumed to be cost effective for both effect measures. Therefore and due to comparable safety, TLH should be recommended as a standard-of-care surgical procedure in early endometrial cancer., (Copyright © 2010 Elsevier Inc. All rights reserved.)

We have developed and validated a rapid molecular screening protocol for toxigenic Clostridium difficile, that also enables the identification of the hypervirulent epidemic 027/NAP1 strain. We describe a multiplex real-time PCR assay, which detects the presence of the tcdA and tcdB genes directly in stool samples. In case of positive PCR results, a separate multiplex real-time PCR typing assay was performed targeting the tcdC gene frame shift mutation at position 117. We prospectively compared the results of the screening PCR with those of a cytotoxicity assay (CTA), and a rapid immuno-enzyme assay for 161 stool samples with a specific request for diagnosis of C. difficile infection (CDI). A total of 16 stool samples were positive by CTA. The screening PCR assay confirmed all 16 samples, and gave a PCR positive signal in eight additional samples. The typing PCR assay detected the tcdC Δ117 mutation in 2/24 samples suggesting the presence of the epidemic strain in these samples. This was confirmed by PCR ribotyping and sequencing of the tcdC gene. Using CTA as the "gold standard", the sensitivity, specificity, positive predictive value, and negative predictive value, for the screening PCR were 100%, 94.4%, 66.7%, and 100%, respectively. In conclusion, PCR may serve as a rapid negative screening assay for patients suspected of having CDI, although the low PPV hamper the use of PCR as a standalone test. However, PCR results may provide valuable information for patient management and minimising the spread of the epidemic 027/NAP1 strain., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Background: The standard surgery for early-stage endometrial cancer is total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy, which is associated with substantial morbidity. Total laparoscopic hysterectomy (TLH) and bilateral salpingo-oophorectomy is less invasive and is assumed to be associated with lower morbidity, particularly in obese women. This study investigated the complication rate of TLH versus TAH in women with early-stage endometrial cancer., Methods: This randomised trial was done in 21 hospitals in The Netherlands, and 26 gynaecologists with proven sufficient skills in TLH participated. 283 patients with stage I endometrioid adenocarcinoma or complex atypical hyperplasia were randomly allocated (2:1) to the intervention group (TLH, n=187) or control group (TAH, n=96). Randomisation by sequential number generation was done centrally in alternate blocks of six and three participants, with stratification by trial centre. After assignment, the study coordinators, patients, gynaecologists, and members of the panel were not masked to intervention. The primary outcome was major complication rate, assessed by an independent panel. Data were analysed by a modified intention-to-treat analysis, since two patients in both groups were excluded from the main analysis. This trial is registered with the Dutch trial registry, number NTR821., Findings: The proportion of major complications was 14.6% (27 of 185) in the TLH group versus 14.9% (14 of 94) in the TAH group, with a difference of -0.3% (95% CI -9.1 to 8.5; p=0.95). The proportion of patients with an intraoperative major complication (nine of 279 [3.2%]) was lower than the proportion with a postoperative major complication (32 of 279 [11.5%]) and did not differ between TLH (five of 185 [2.7%]) and TAH (four of 94 [4.3%]; p=0.49). The proportion of patients with a minor complication was 13.0% (24 of 185) in the TLH group and 11.7% (11 of 94) in the TAH group (p=0.76). Conversion to laparotomy occurred in 10.8% (20 of 185) of the laparoscopic procedures. TLH was associated with significantly less blood loss (p<0.0001), less use of pain medication (p<0.0001), a shorter hospital stay (p<0.0001), and a faster recovery (p=0.002), but the procedure took longer than TAH (p<0.0001)., Interpretation: Our results showed no evidence of a benefit for TLH over TAH in terms of major complications, but TLH (done by skilled surgeons) was beneficial in terms of a shorter hospital stay, less pain, and quicker resumption of daily activities., Funding: The Dutch Organization for Health Research and Development (ZonMw), programme efficacy., (2010 Elsevier Ltd. All rights reserved.)

The clinical impact of incontinence in pregnancy and after childbirth is growing because some studies report the efficacy of physiotherapy in pregnancy and because obstetric choices are supposed to have significant impact on post-reproductive urinary function (Goldberg et al. in Am J Obstet Gynecol 188:1447-1450, 2003). Thus, the need for objective measurement of urinary incontinence in pregnancy is growing. Data on pad testing in pregnancy are lacking. We assessed the clinical relevance of the 24-h pad test during pregnancy and after childbirth, compared with data on self-reported symptoms of urinary incontinence and visual analogue score. According to the receiver operating characteristic curve, the diagnostic value of pad testing for measuring (severity of) self-reported incontinence during pregnancy is not of clinical relevance. However, for the purposes of research, pad tests, combined with subjective/qualitative considerations, play a critical role in allowing comparisons across studies, quantifying the amount of urine loss and establishing a measure of severity.

Aims: (i) To describe the displacement and recovery of the vesical neck position during pregnancy and after childbirth and (ii) to discriminate between compliance of the vesical neck supporting structures with and without pelvic floor contraction., Methods: We focussed on the biomechanical properties of the vesical neck supporting structures during pregnancy and after childbirth by calculating the compliance and the hysteresis as a result from of abdominal pressure measurements and simultaneous perineal ultrasound., Results: This study shows that compliance of the supporting structures remains relatively constant during pregnancy and returns to normal values 6 months after childbirth. Hysteresis, however, showed an increase after childbirth, persisting at least until 6 months post partum., Conclusions: Vaginal delivery may stretch and or load beyond the physiological properties of the pelvic floor tissue and in this way may lead to irreversible changes in tissue properties which play an important role in the urethral support continence mechanism.

Objective: To assess the incidence of urinary incontinence in pregnancy and after spontaneous vaginal delivery and its relation with changes in the static and dynamic function of the pelvic floor., Design: The second part of a prospective longitudinal study., Setting: University Hospital Groningen and Martini Hospital Groningen, the Netherlands., Population: A cohort of 62 women before and after spontaneous vaginal delivery at term and 27 nulliparous non-pregnant controls., Methods: Urinary incontinence was measured by a questionnaire and by a 24 hour pad test. The position and mobility of the urethrovesical junction were measured by perineal ultrasound and related to simultaneously measured abdominal pressure changes. Serial investigations were done at 38 weeks of gestation and at 6 weeks and 6 months after delivery., Main Outcome Measures: Urinary incontinence and its relation with the position of the urethrovesical junction at rest and with the mobility of the urethrovesical junction during Valsalva and during coughing, indicated by the displacement/pressure coefficient and with obstetric variables., Results: After delivery, reported urinary incontinence was reduced from 26% at 38 weeks of gestation to 16% and 15% at 6 weeks and 6 months after delivery, respectively. Even lower rates were measured by the 24 hour pad test, which revealed a decrease from 14% at 38 weeks to 10% and 5% at 6 weeks and 6 months postpartum, respectively. Six weeks and six months after delivery, the angle of the urethrovesical junction at rest was significantly increased compared with the non-pregnant control women. Compared with the antenatal measurements, the displacement/pressure coefficients during coughing and during the Valsalva manoeuvre were significantly increased six weeks after delivery. Six months after delivery, only the coefficient for coughing was still significantly greater than the antenatal value and the value in the non-pregnant control group. No relations were found between urethrovesical junction measurements and obstetric variables and subjective or objective urinary incontinence parameters., Conclusion: Although pregnancy and spontaneous vaginal delivery significantly increased the degree of bladder neck descent during coughing, urinary incontinence, quite common during pregnancy, occurs less frequently postpartum.

Objective: To assess the prevalence and the development of urinary incontinence in nulliparous pregnant women, both subjectively and objectively, and to investigate the relation of incontinence with the mobility of the urethro-vesical junction measured by perineal ultrasound., Design: A prospective longitudinal study., Setting: University Hospital and Martini Hospital Groningen, the Netherlands., Population: A cohort of 117 nulliparous pregnant women and 27 nulliparous non-pregnant controls., Methods: Urinary incontinence was measured by a questionnaire and by a 24-hour pad test. The position of the urethro-vesical junction and its mobility were measured by perineal ultrasound., Main Outcome Measure: Prevalence of urinary incontinence; mobility of the urethro-vesical junction, indicated by the displacement/pressure coefficient., Results: Up to 35% of the women reported urinary incontinence in pregnancy, and 20% of the women had a positive pad test. The angle of the urethro-vesical junction angle at rest and the displacement/pressure coefficient during coughing showed a significant increasing trend during pregnancy, but no changes were seen during the Valsalva manoeuvre. No relationship was found between subjective and objective incontinence data and the position and mobility of the urethro-vesical junction., Conclusion: The prevalence of incontinence in nulliparous women as found by the pad test was significantly higher in pregnancy (20%) than in the non-pregnant control group (4%). Perineal ultrasound of the urethrovesical junction showed lowering of the pelvic floor occurring as early as 12-16 weeks of pregnancy. Serial measurements of the displacement/pressure coefficient suggest that the dynamic characteristics of the connective tissues of the pelvic floor remain unaltered,whereas a significant decrease in pelvic floor muscle contraction occurs. Since no relation was found between measurements of the urethro-vesical junction and incontinence, urinary incontinence in pregnancy is most likely explained by other factors.

With a curved array real-time ultrasound scanning machine and the probe placed sagitally onto the vulva, symphysis, bladder, urethra and the pelvic floor can be visualized in one frame. With this technique we studied 10 women with stress incontinence and 10 control women. In both groups active contraction of the pelvic floor resulted in a similar elevation of the urethrovesical junction (UVJ). During Valsalva maneuver an equal descent of the UVJ was found in patients and controls. During coughing a significant descent of the UVJ only occurred in the patient group. This suggests that women with stress incontinence are capable of operating the pelvic floor muscles but do not use them adequately during a cough.

A randomized prospective study compared the efficacy of a three-dose perioperative course of intravenously administered cefuroxime and metronidazole versus suction drainage of the vaginal vault for preventing postoperative infection in abdominal and vaginal hysterectomies. In vaginally operated patients, a significant difference in the rate of vaginal cuff abscess formation was found between the drain group and the antibiotic group (33 versus 0%). In the abdominally operated patients, no significant difference was found (7 versus 0%). The rate of cystitis was not influenced by the prophylactic method. A positive correlation was found between Bacteroides sp isolated from the vaginal fluid and vaginal cuff abscesses in the vaginally operated women. The complications of infection are explained by the decrease in host defense, occurring more frequently in patients treated with the vaginal approach than with the abdominal technique.