Original research publications

This study aimed to investigate the sex difference in uphill performance of Master runners. We tested the hypothesis that aging would reduce this difference, with the aging-induced performance decline being smaller in females than in males. We also analyzed changes in female participation over the past 20 years, with the hypothesis that increasing participation would be associated with a narrowing of sex differences during this period. Data were extracted from the uphill races of the World Masters Mountain Running Championships between 2004 and 2024 and consisted of n = 116 top-3 performances in male and female Master runners (aged 35-69), across 5-year age categories. The sex differences in uphill performance of Master runners were 22.2% (4.9%) and remained similar across ages. Over the 20-year period, sex differences remained constant. There was a linear relationship between the number of female participants and the sex-based performance differences (r = -.31, P < .05). The 22% sex difference reported in Master mountain runners is comparable to that reported in elite athletes. Contrary to our hypotheses, sex differences in uphill running performance did not change across age categories and remained stable over the past 20 years. However, sex differences appeared to narrow as female participation increased, possibly due to the small female sample (approximately 20 on average), where individual performances may have had a greater proportional impact.

Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with lower rates of bleeding and vascular complications than transfemoral access. However, it remains uncertain whether radial (including distal) access fully mitigates these established sex-based disparities in PCI outcomes. We performed a systematic review and meta-analysis to evaluate sex-specific procedural, access-site, and clinical outcomes following radial and distal radial PCI. PubMed, Embase, and Cochrane databases were searched from inception through October 2025 for randomized controlled trials and observational studies reporting PCI outcomes stratified by sex in patients undergoing radial or distal radial access. Outcomes were categorized as procedural, access-site safety, and clinical endpoints. Pooled mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Study quality was assessed using the ROBINS-I tool. Nine studies comprising 214,638 patients (52,486 women and 162,152 men) were included. Compared with men, women had higher rates of access-site crossover (RR 1.87, 95% CI 1.58 to 2.22) and slightly lower procedural success (RR 0.98, 95% CI 0.97 to 0.99), despite shorter procedure duration (MD -3.62 minutes, 95% CI -7.21 to -0.04). Women experienced significantly higher rates of access-site bleeding (RR 1.84, 95% CI 1.23 to 2.75), hematoma (RR 1.70, 95% CI 1.00 to 2.91), and radial artery spasm (RR 3.40, 95% CI 1.30 to 8.87), while radial artery perforation did not differ by sex. Clinically, women had higher cardiovascular mortality (RR 1.75, 95% CI 1.14 to 2.69) and major bleeding (RR 1.51, 95% CI 1.24 to 1.84), but unexpectedly lower target vessel revascularization (RR 0.59, 95% CI 0.36 to 0.95). Rates of all-cause mortality, myocardial infarction, stroke, and major adverse cardiac events were similar between sexes. In conclusion, women undergoing PCI via radial or distal radial access experienced higher rates of access-site complications, major bleeding, and cardiovascular mortality than men, whereas ischemic outcomes were generally similar between sexes. These findings suggest that sex-related differences may persist despite the widespread use of radial access. However, the contribution of vascular access itself to these differences remains uncertain, as other clinical and procedural factors may also influence outcomes.

This study aims to assess the association between HIV infection and cardiovascular disease (CVD) incidence, with a focus on sex differences and the role of immune status. Retrospective cohort study using electronic health records from the All of Us (AoU) Research Program. We identified people with HIV (PWH) and matched them to people without HIV (PWoH) using propensity score matching (PSM) (1 : 5) by sex, age, and race/ethnicity. The matched cohort was then restricted to participants who were free of CVD before the index date. We used Cox proportional hazards models, including an interaction term between sex and HIV status, to assess sex differences in the association between HIV status and incident CVD, adjusting for potential confounders. Subgroup analyses evaluated effect modification by viral suppression (HIV RNA < 50 copies/ml) and preserved immune function (CD4 + cell count >500 cells/μl). After PSM, we identified 4803 PWH without preexisting CVD and matched them with 24 276 PWoH. Compared to their matched PWoH, women with HIV had an elevated adjusted hazard ratio (aHR) for CVD [aHR = 1.933, 95% confidence interval (CI): 1.709-2.188] than men with HIV (aHR = 1.435, 95% CI: 1.313-1.568). In subgroup analyses, compared with women without HIV, women with HIV remained at higher risk of CVD despite viral suppression (aHR = 1.929, 95% CI: 1.565-2.378) or preserved immune function (aHR = 1.813, 95% CI: 1.455-2.259). In contrast, no significant differences were observed between men with HIV and well controlled men without HIV (aHR = 1.133, 95% CI: 0.964-1.332). Understanding sex-specific drivers of CVD risk is crucial for developing targeted interventions to prevent CVD in women with HIV and men with HIV.

Globally, 1 in 5 maternal deaths are attributable to major postpartum hemorrhage (PPH), despite widespread uterotonic use. Intrauterine tamponade is recommended as second-line therapy for refractory atonic PPH. Uterine balloon tamponade (UBT) achieves hemostasis through intrauterine pressure. Conversely, the vacuum-assisted hemorrhage-control device (VHD) promotes uterine contraction through negative pressure. Limited data compare these modalities. We compared the clinical effectiveness of UBT and VHD in refractory atonic PPH. This retrospective cohort study was conducted at the National University Hospital in Singapore and included all women treated for primary PPH with either the UBT or VHD between January 2020 and September 2025, during which ROTEM-guided transfusion and E-MOTIVE-aligned practices were implemented. The composite morbidity endpoint, comprising transfusion of ≥4 units of packed red blood cells (PRBC), plasma or cryoprecipitate administration, examination under anesthesia, high dependency or intensive care unit admission, or device failure was compared between groups with logistic regression adjusted for placenta previa major and cesarean delivery. Fifty-three women met inclusion criteria (33 UBT, 20 VHD). The composite morbidity outcome occurred less frequently with VHD than UBT (45.0% versus 75.8%; unadjusted OR 0.26, 95% CI 0.08-0.86, p = 0.03); after adjusting for placenta previa major and cesarean delivery, this difference was no longer statistically significant (adjusted OR 0.38, 95% CI 0.10-1.41, p = 0.15). Baseline characteristics were similar except for higher rates of placenta previa (45.5% versus 5.0%) and cesarean delivery (78.8% versus 50.0%) in the UBT group. Median estimated blood loss at device insertion was comparable (1500 mL). Among secondary outcomes, VHD was associated with lower median PRBC transfusion (1 vs. 2 units, p = 0.009), fewer women receiving ≥4 PRBC units (5.0% versus 36.4%, p = 0.02), fewer plasma transfusions (5.0% versus 36.4%, p = 0.02), shorter device indwelling duration (10.1 versus 24.3 h, p < 0.001), shorter hospital stay (54 versus 72 h, p = 0.007), and fewer high-dependency admissions (45.0% versus 72.7%, p = 0.04). The VHD demonstrated outcomes comparable to balloon tamponade in managing refractory atonic PPH, with lower transfusion requirements and shorter hospitalization. VHD may be a useful component of standardized PPH protocols incorporating the E-MOTIVE bundle and ROTEM-guided transfusion, warranting further evaluation in broader clinical settings.

Congenital uterine anomalies (UA) result in an increased risk for infertility and miscarriage but there are few population-based studies investigating the prevalence and associations between UA and pregnancy and perinatal outcomes. This nationwide cohort study includes 599 840 singleton births of primiparas from ≥22 gestational weeks in Sweden between 2010-2022. The risk for adverse pregnancy and perinatal outcomes was compared between women diagnosed with/or treated for UA and those without diagnoses for UA. Logistic regression was used to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI). There were 1101 (0.2%) women diagnosed with UA. Compared with no UA, UA were associated with an increased risk of preterm birth <34 weeks (aOR 9.10 CI [7.64-10.83]), breech presentation (aOR; 25.46 95% CI [22.59-28.70]), placental abruption (aOR; 5.09 95% CI [3.23-8.03]), emergency caesarean section (aOR: 2.96 [(2.60-3.3]), manual removal of placenta, (aOR:1.73 [1.29-2.33]) and infant small for gestational age (aOR; 2.60 95% CI [(2.11-3.21)]) but not with oligohydramnios, uterine rupture or chorioamnionitis. UA was associated with an increased risk of adverse perinatal and intrapartum outcomes, including, preterm birth, infant being small for gestational age, emergency caesarean section and maternal complications including bleeding and manual removal of the placenta. These findings highlight the importance of awareness of these pregnancies in clinical practice to support appropriate monitoring during pregnancy and intrapartum management. Women with congenital uterine anomalies face substantially higher risks of adverse pregnancy and birth outcomes in a nationwide Swedish cohort of primiparas. These findings add crucial knowledge to guide tailored antenatal and intrapartum care for women with known uterine anomalies.

To compare residual myometrial thickness and cesarean scar elastography findings following single- versus double-layer uterine closure in women undergoing primary cesarean delivery. In this prospective comparative cohort study, 100 women undergoing primary cesarean delivery at Izmir City Hospital between November 2024 and February 2025 were included. Participants were allocated according to the operating surgeon's routine uterine closure technique into single-layer (n = 50) and double-layer (n = 50) groups. Maternal characteristics, perioperative outcomes, hemoglobin changes, postoperative pain scores, and the requirement for additional hemostatic sutures were recorded. At 6 weeks postpartum, residual myometrial thickness, endometrial thickness, and cesarean scar elastography were assessed by ultrasonography. Exploratory receiver operating characteristic (ROC) analysis was performed to evaluate the discriminatory performance of the imaging parameters. Baseline demographic and perioperative characteristics were comparable between groups. The single-layer group required more additional intraoperative hemostatic sutures than the double-layer group (p = .002). Perioperative hemoglobin decline, postoperative pain scores, operative duration, and hospital stay did not differ significantly (all p > .05). Residual myometrial thickness (5.7 versus 4.9 mm, p = .001), endometrial thickness (7.9 versus 6.4 mm, p = .042), and elastography scores (11.1 versus 8.2, p < .001) were significantly greater following double-layer closure. Elastography demonstrated the highest discriminatory performance in the exploratory ROC analysis (AUC = 0.827). Double-layer uterine closure was associated with greater residual myometrial thickness, higher cesarean scar elastography scores, and a reduced need for additional hemostatic sutures than single-layer closure. These findings indicate more favorable early postoperative scar characteristics; however, their clinical significance and implications for long-term reproductive and obstetric outcomes remain uncertain.

Uterine fibroids are the most common tumour of the female genital tract and represent a major cause of gynaecological morbidity. Management options have expanded in recent years, including minimally invasive surgical techniques and emerging medical and incisionless therapies. However, access to these treatments may vary geographically. This study aimed to explore current practice patterns, availability of interventions, and clinician perspectives on the future organisation of fibroid services in the United Kingdom. A pilot survey of UK gynaecologists was conducted using an online questionnaire developed by a focus group of clinicians with expertise in fibroid management. The survey assessed availability of treatment modalities, imaging preferences, surgical practices, and opinions on service organisation. The questionnaire was disseminated through the British Society for gynaecological endoscopy newsletter and at the society's 2024 annual scientific meeting. Responses were analysed using descriptive statistics. Fifty UK-based clinicians were included in the analysis. Established surgical interventions, including abdominal, laparoscopic, and hysteroscopic myomectomy, were widely available. However, access to newer technologies varied between regions. Radiofrequency ablation was available in five of nine regions represented, while high-intensity focused ultrasound was not available to any respondents. Most clinicians reported access to MRI for fibroid mapping, although specialist ultrasound availability was more variable. Minimally invasive myomectomy was performed by 60% of respondents. The majority supported referral to specialised centres when local expertise was unavailable. Most respondents favoured multidisciplinary discussion for complex cases and supported a more centralised model of fibroid care. This survey highlights variation in access to fibroid treatments across the UK and identifies support among clinicians for more structured and centralised fibroid services. These findings support the need for further national evaluation and service development to improve equitable access to comprehensive fibroid care. Uterine fibroids are non-cancerous growths of the womb and are the most common tumour in women of reproductive age. They can cause heavy bleeding, pain, pressure symptoms, infertility, and pregnancy complications. Treatments include medication, minimally invasive procedures, and surgery, but access varies across the United Kingdom.This study examined how fibroids are managed and explored doctors’ views on current and future services. An anonymous survey of UK gynaecologists gathered information on available treatments, decision-making, and service organisation.Fifty clinicians responded. Most reported good access to established surgeries such as myomectomy (surgical removal of fibroids) and hysterectomy (surgical removal of the womb). However, access to newer treatments like radiofrequency ablation (a minimally invasive, outpatient procedure that shrinks uterine fibroids without surgery) was limited, and none reported access to high-intensity focused ultrasound (a non-surgical treatment that uses sound waves to shrink painful fibroids). Many supported developing specialised centres offering a full range of treatments.These findings highlight ongoing inequalities in access and suggest that more coordinated services could improve equitable care.

Placenta accreta spectrum (PAS) is a rare complication associated with significant maternal morbidity and mortality. Historically, 2 surgical approaches emerged in the management of PAS, namely, hysterectomy or leaving the placenta in situ, hoping to avoid surgical morbidity and preserve future fertility. In this article, we argue that the risks of intentional placental retention for managing PAS outweigh the benefits, leaving patients unnecessarily exposed to the ongoing risk of hemorrhage and hysterectomy, with prolonged intensive follow-up required. Furthermore, histopathologic findings for these cases are inherently lacking, further limiting our ability to fully understand the underlying etiology of these cases.

To develop and validate a radiomics-clinical model for individualized prediction of the initial treatment dose in focused ultrasound ablation surgery (FUAS) for uterine fibroids. This retrospective study included 210 patients with solitary uterine fibroids who underwent FUAS and were randomly divided into training and testing cohorts (7:3). The outcome variable was defined as the total sonication energy delivered to the initial treatment layer. Regions of interest were manually delineated on preoperative T2-weighted MRI, and radiomics features were extracted using PyRadiomics. After feature selection, multiple machine-learning algorithms were evaluated, and the optimal radiomics model was combined with independent clinical predictors to construct a radiomics-clinical model. Model performance was assessed using receiver-operating-characteristic analysis and decision curve analysis (DCA). A total of 1,223 radiomics features were extracted, of which 10 were retained for model construction. Body mass index (BMI), rectus abdominis thickness, and preoperative surgical score were identified as independent clinical predictors. The combined radiomics-clinical model demonstrated the best predictive performance, with an AUC of 0.862 (95% CI, 0.821-0.898) in the training cohort and 0.803 (95% CI, 0.756-0.845) in the testing cohort. DCA demonstrated greater clinical net benefit for the combined model compared with either the radiomics or clinical model alone. MRI-based radiomics combined with clinical variables may provide a useful approach for individualized prediction of the initial FUAS treatment dose for uterine fibroids.

To compare the effects of high-intensity focused ultrasound (HIFU) ablation and laparoscopic myomectomy on ovarian function and endometrial receptivity in patients with uterine fibroids. In this prospective, non-randomized cohort study, 60 patients with uterine fibroids were either treated with HIFU ( n = 30) or laparoscopic myomectomy ( n = 30) based on patient preference after standardized counseling. Ovarian function and endometrial receptivity were evaluated preoperatively and at 1, 3, and 6 months post‑treatment. Ovarian reserve was assessed using anti‑Müllerian hormone (AMH), sex hormone levels of luteinizing hormone (LH), follicle‑stimulating hormone (FSH), estradiol (E2), and antral follicle count (AFC). Endometrial receptivity was evaluated using endometrial thickness and vascular indices, including endometrial artery resistance index (RI), pulsatility index (PI), and the systolic/diastolic velocity ratio (S/D). Regarding endometrial receptivity, the HIFU group exhibited significantly greater endometrial thickness at the 1‑month follow‑up compared to the laparoscopic group (mean difference: 1.5 mm, 95% CI: 0.6 to 2.4 mm; Cohen's d = 0.72, p < 0.05). Both groups showed a reduction in PI after treatment, though the change was not statistically significant. RI and S/D ratios were comparable between the two groups at any time point ( p > 0.05). Both HIFU and laparoscopic myomectomy preserved ovarian function in patients with uterine fibroids. HIFU was associated with faster short-term endometrial recovery at 1 month post-treatment, but no differences in ovarian function or other receptivity markers were observed between the two groups of patients. Randomized trials with pregnancy outcomes are needed before clinical recommendations can be made.

In this case series, we describe a novel technique for the treatment of large cystic fibroids causing pressure on the diaphragm and dyspnoea during pregnancy. In all three cases, patients developed breathing difficulties prior to 28 weeks' gestation. The aim of treatment was to enable continuation of pregnancy and prevent iatrogenic early preterm birth. We performed transabdominal ultrasound-guided aspiration of fibroids under local anaesthesia in the outpatient setting between 24 and 31 weeks' gestation. The volumes of fluid aspirated were 600 ml, 1700 ml and 2000 ml. The procedures were uncomplicated, and all patients continued their pregnancy until elective caesarean delivery between 34 and 37 weeks' gestation. This series shows that antenatal ultrasound-guided aspiration may be a simple, safe and effective option for the treatment of symptomatic cystic fibroids, allowing pregnancy to continue without patients being exposed to surgical or anaesthetic risks, and preventing the major neonatal sequelae of very preterm birth.

To investigate the impact of hemoglobin (HGB) levels on therapeutic efficacy and energy dosage during ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation of symptomatic uterine fibroids (UFs). A total of 1196 patients who underwent USgHIFU for symptomatic UFs were retrospectively enrolled. Patients were stratified into 8 subgroups based on preprocedural HGB concentrations (g/L): <60, 60-70, 70-80, 80-90, 90-100, 100-110, 110-120, and >120. The energy efficiency factor (EEF) was used to quantify the ablation dose, and non-perfused volume ratio (NPVR) was adopted to evaluate ablation efficacy. The overall median EEF was 3.96 J/mm 3 . EEF was significantly lower in the <60 (3.63 J/mm 3 ) and 60-70 g/L (4.75 J/mm 3 ) groups than in the 80-90 g/L group (6.62 J/mm 3 ), and the 80-90 g/L group had higher EEF than the >120 g/L group. The proportion of T2-weighted imaging hyperintense fibroids (Funaki type 3) and NPVR was both higher in the 80-90 g/L group than in the >120 g/L group. Lower preprocedural HGB levels correlate with higher NPVR. During moderate anemia, EEF increases with rising HGB, which may serve as useful reference evidence for individualized energy dose adjustment in clinical practice.

Since its introduction in 2010, Ultrasound-guided High-Intensity Focused Ultrasound (USgHIFU) has rapidly expanded in South Korea, despite the absence of widely accepted standardized clinical protocols. This study evaluated the long-term clinical outcomes of USgHIFU and proposed a standardized MRI-integrated treatment framework incorporating MRI-based planning, treatment verification, and structured follow-up. In this retrospective analysis, we included 2,992 patients (1,620 with uterine fibroids and 1,372 with adenomyosis) treated with USgHIFU between 2010 and 2025. Therapeutic efficacy was assessed using non-perfused volume (NPV) ratio, volume reduction rates (VRR), and reintervention rates. Long-term durability, defined as freedom from reintervention, was evaluated using Kaplan-Meier analysis in 476 patients with follow-up durations of 3-9.7 years. Immediate post-treatment contrast-enhanced MRI demonstrated a mean NPV ratio of 86.5 ± 7.2%, with 94.2% of patients achieving an NPV ratio ≥ 80%. At 12 months, the mean VRRs were 77.4% and 61.4% for fibroids and adenomyosis, respectively. In the long-term follow-up subset ( n = 476), volume reduction was maintained and then increased, reaching 78.8% for fibroids and 66.3% for adenomyosis at 3-9.7 years. Freedom from reintervention was 99.1% at 12 months, 98.4% at 3 years, and 97.6% at 9.7 years. No major complications were observed after implementation of the standardized treatment framework. Standardized USgHIFU treatment, achieving an NPV ratio ≥ 80%, is associated with sustained long-term clinical outcomes and a favorable safety profile. These findings support the clinical value of a standardized MRI-integrated treatment framework and may contribute to future clinical standardization of USgHIFU practice.

To investigate the changes in the metabolome of fibroid tissue after high-intensity focused ultrasound (HIFU) treatment, providing insights into its potential mechanisms of action. Thirty patients with uterine fibroids who scheduled for hysterectomy were included. Among them, 15 patients had HIFU previously (HIFU group), and 15 patients did not receive HIFU (Control group). The tissues of treated fibroid, myometrium, endometrium, and new-emerging fibroids were collected. Gas chromatography-mass spectrometry (GC-MS) was applied for metabolomic analysis. GC-MS metabolomics analysis identified 94 metabolites. There was no significant difference in metabolite profile between the newly emerged fibroid tissue in the HIFU group and fibroid tissue in the Control group, and also no significant difference in the myometrial tissue and endometrial tissue between the two groups. In contrast, a significant difference was observed in metabolites between the treated fibroid tissue and the myometrial tissue in HIFU group. The levels of malus pumila acid, dimethyl fumarate, fumaric acid, methylphenylacetic acid, benzoic acid, and phosphoenolpyruvic acid were significantly higher ( p < 0.05), and acetophenone, hexanoic acid, and idketoglutaric acid monoamide exhibited significantly decreased levels in the HIFU group ( p < 0.05). Biomarker analysis revealed that malus pumila acid and nicotinic acid were elevated in the HIFU group, whereas erketoglutaric acid monoamide, hexanoic acid, and acetophenone were significantly reduced ( p < 0.05). HIFU ablation may have a reprogramming effect on energy metabolism in the treated fibroids. The findings of this study provide a new direction for exploring the future development of biomarkers for combined metabolic regulation therapy.

To explore the predictive value of machine learning-based multimodal MRI radiomics combined with clinical features in the efficacy of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids. This study included 390 patients with uterine fibroids who underwent HIFU ablation. Patients were stratified into high and low ablation groups based on an 80% non-perfused volume ratio (NPVR) and randomly divided into training (70%) and test (30%) sets. Radiomics features were extracted from T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and diffusion-weighted imaging (DWI). The most predictive features were selected via Recursive Feature Elimination (RFE) and the Least Absolute Shrinkage and Selection Operator (LASSO), and combined with clinical characteristics. Logistic Regression (LR), Random Forest (RF) and eXtreme Gradient Boosting (XGBoost), were constructed to predict ablation efficacy, with performance assessed using the area under the receiver operating characteristic curve (AUC). The results indicated that age, uterine fibroid location, and T2WI signal intensity were independent predictive factors ( p < 0.05). The multimodal-clinical fusion XGBoost model exhibited the optimal performance. In the test set, this model achieved an AUC of 0.894, with an accuracy of 82.1%, sensitivity of 88.9%, and specificity of 74.1%.The calibration curve and decision curve analysis (DCA) confirmed that the predicted probabilities of the model were highly consistent with the actual risks, and stable clinical net benefits were achieved. The XGBoost model based on multimodal MRI and clinical features may serve as a reference for predicting HIFU ablation efficacy and optimizing treatment strategies.

This study aimed to develop and validate a nomogram for predicting high-intensity focused ultrasound (HIFU) ablation efficacy in uterine fibroids, based on the Oxytocin-Induced Arterial-phase Perfusion Delay Time(APDT) on contrast-enhanced ultrasound (CEUS), combined with ultrasound features. A retrospective analysis was performed on 53 patients (76 fibroids) who underwent oxytocin-assisted HIFU treatment. All patients underwent abdominal ultrasound before HIFU, with APDT on CEUS recorded pre- and post-oxytocin challenge. Predictive factors were identified via univariate and multivariate logistic regression analyses. A clinical efficacy prediction model for HIFU treatment was established using R software and visualized as a nomogram. Its discriminative ability, calibration performance, and clinical utility were evaluated. The final predictive factors included the number of intratumoral attenuation bands, oxytocin-induced APDT, peripheral blood flow grade, and location/type of fibroids. The nomogram's calibration curve demonstrated excellent agreement between observed and predicted values (absolute error = 0.034). The discriminative ability, assessed by the area under the receiver operating characteristic curve (AUC), was 0.884 (95% CI: 0.803-0.965). The model achieved a sensitivity of 92.7% and specificity of 76.2%, indicating strong predictive value for ablation outcomes. Decision curve analysis revealed high clinical utility with a maximum net benefit threshold probability range of 0%-97%. The HIFU ablation efficacy prediction model, integrating oxytocin-induced Arterial-phase Perfusion Delay Time and ultrasound features, demonstrated robust predictive performance and may assist clinicians in selecting suitable candidates for HIFU treatment.

In MR-guided high-intensity focused ultrasound (MR-HIFU) treatment for uterine fibroids, the subcutaneous abdominal fat layer is prone to unwanted heating, especially during consecutive sonications. Automating its delineation with a deep learning algorithm would enhance treatment safety, efficiency and simplify clinical workflow. The subcutaneous fat layer was manually segmented on MR images from 62 patients treated with MR-HIFU. An attention gated U-Net convolutional neural network (CNN) was trained and validated using the Dice coefficient (DC). Model performance was tested using the DC and 95th percentile Hausdorff distance (HD95). The clinically relevant accuracy was assessed by the average fat layer thickness. The model's transferability was determined on data prepared by a second reader and compared to the interobserver variability. The model achieved a DC of 0.972 (IQR: 0.951-0.983), and an HD95 of 1.1 (IQR: 0.8-3.2) mm on the held-out test dataset. The mean absolute thickness error between ground truth and the model's prediction was 0.8 ± 0.8 mm for the test dataset, and was 0.7-0.8 mm on the two patients prepared by the secondary reader. The automated segmentation algorithm successfully reduced the segmentation time from 3 min to 3 s. We established an automatic segmentation algorithm based on an attention-gated U-Net architecture to delineate the abdominal fat layer in MR images of uterine fibroids patients. The model achieved high accuracy, robustly handling both thin and thick fat layers, and performed reliable on data prepared by a second reader.

This paper presents a comprehensive approach for managing uterine prolapse during first-trimester pregnancy complicated by poor obstetric history. A prophylactic cervical cerclage and an adjunctive ring pessary were used to maintain cervical integrity and achieve successful term delivery. A 43-year-old woman, Gravida 12, Para 2, with a history of recurrent pregnancy losses, including a second-trimester loss attributable to cervical incompetence, presented with stage III uterine prolapse at 11 weeks of gestation. Prophylactic McDonald cerclage was performed at 12 weeks, after which a ring pessary and vaginal progesterone were utilized. The pregnancy was successfully managed to term, resulting in vaginal delivery at 38 + 5 weeks of a baby with birth weight of 2790 g and an Apgar score of 9/9. This case highlights the successful use of cervical cerclage and a pessary for managing uterine prolapse complicated by cervical incompetence during pregnancy, emphasizing the need for personalized management strategies.

Serous carcinomas are copy-number-high (p53-abnormal) endometrial carcinomas with adverse outcomes. We aimed to assess the prognostic value of classic morphologic features in these tumors. Treatment-naive uterine serous carcinomas diagnosed from 1995 to 2022 were identified, and clinical-pathologic features were evaluated. The median age was 71 (52 to 95) years. Of 138 tumors, most (87 [63%]) were myoinvasive, and 51 (37%) were endometrium-confined, including 11 (21.6%) with only intraepithelial growth and 40 (78.4%) with stromal invasion within polyps and/or background endometrium. Predominant growth pattern was papillary in 63 tumors (45.6%), glandular in 60 (43.5%), and solid in 15 (10.9%). Lymphovascular invasion (LVI) was present in 49 (35.5%) cases, with nodal micro/macrometastases in 25/106 (23.6%) and isolated tumor cells in 3/106 (2.8%). Of 126 patients with follow-up (median: 38 mo, 0.9 to 230.7), 49 (38.9%) experienced recurrences and 27 (21.4%) died of disease. Both recurrence-free and disease-specific survival were associated with T category of pTNM staging, FIGO stage, endometrial stromal invasion, myoinvasion, margin status, cervical, lower uterine segment, and uterine serosal involvement (all P <0.0001), LVI ( P ≤0.002), predominant growth pattern, surrounding intraepithelial growth, and multinucleated tumor cells ( P ≤0.01). Patients with only intraepithelial growth experienced no recurrence or cancer-related death. LVI was associated with decreased recurrence-free ( P <0.0001) and disease-specific ( P <0.001) survival regardless of extent. T category ( P =0.0049) and uterine serosal involvement ( P =0.0514) were independent predictors of recurrence-free survival, with T category ( P =0.03) also predicting disease-specific survival. The presence of only intraepithelial growth portends a favorable prognosis in serous carcinoma, whereas the clinical significance of the extent of LVI is limited.

Uterine tumor resembling ovarian sex-cord tumor (UTROSCT) is an extremely rare uterine stromal neoplasm of uncertain origin that accounts for less than 0.5% of uterine malignancies. Here, we report, using MRI, 18 F-FDG, and 68 Ga-FAPI-04 PET/CT, the imaging findings for peritoneal metastatic lesions from postoperative UTROSCT in a 58-year-old woman. The peritoneal lesions showed only mild uptake on 18 F-FDG PET/CT. Subsequent 68 Ga-FAPI-04 PET/CT revealed intense tracer uptake in the lesions, indicating the potential value of this modality for detecting recurrence and metastasis in UTROSCT.

In this clinical perspective, we examine the role of gonadotropin-releasing hormone (GnRH) antagonist combination therapies in the management of uterine leiomyomas during perimenopause, a period marked by hormonal variability and heightened symptom burden. Drawing on mechanistic comparisons, randomized trial data, and long-term safety findings, we review evidence demonstrating that GnRH antagonist combination therapies provide rapid, reversible suppression of gonadotropin secretion without an estrogen flare. This, in turn, results in consistent reductions in heavy menstrual bleeding associated with leiomyomas, management of bulk-related symptoms, and improvement with anemia. We further highlight limitations of conventional hormonal and expectant management strategies during perimenopause and discuss practical considerations for patient selection and monitoring. Collectively, these findings support GnRH antagonist combination therapy as a targeted, time-limited, and well-tolerated treatment option that addresses a critical therapeutic gap for perimenopausal patients with symptomatic uterine leiomyomas.

This study aimed to develop an intelligent framework, termed CUA-Net, for the automated classification of congenital uterine anomalies (CUAs) without the requirement of coronal plane reconstruction, and to evaluate its clinical applicability. CUA-Net was built on 3-D ResNet-18, equipped with a dynamic data re-sampling strategy to mitigate the data imbalance issue and a hard sample mining technique to fully learn from difficult cases through loss adjustment. We further proposed self-supervised reconstruction to comprehensively explore volumes and online data augmentation to refine incorrect predictions and enhance the model's generalization. We used internal and external test sets to compare CUA-Net with different deep learning methods as well as junior/senior sonographers. The evaluation metrics included accuracy, precision, recall, F 1 -score, micro-area under the curve (AUC) and macro-AUC. CUA-Net exhibited satisfactory performance in both the internal and external test sets. In the internal cohort, the model achieved an accuracy of 93.88%, precision of 87.01%, recall of 95.92%, F 1 -score of 88.09%, micro-AUC of 0.9982 and macro-AUC of 0.9997. In the external set, it maintained good performance with an accuracy of 91.52%, precision of 83.27%, recall of 88.63%, F 1 -score of 81.49%, micro-AUC of 0.9945 and macro-AUC of 0.9990. CUA-Net outperformed junior sonographers across all performance indicators and achieved performance comparable to that of senior sonographers across most metrics. CUA-Net demonstrates favorable accuracy and generalizability in classifying common CUA categories while showing preliminary potential for recognizing less prevalent anomalies. These capabilities may help to optimize clinical workflows and support more standardized diagnosis.

To investigate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for uterine fibroids in patients with abdominal wall scars on the acoustic pathway. A total of 608 patients were included in the retrospective analysis. Preoperative and postoperative pelvic MRI data, treatment data, and follow-up information were collected. Patients were divided into scar group (213 cases: 172 transverse and 41 longitudinal abdominal wall scars) and non-scar group (395 cases). Treatment efficacy, adverse events, and complications were compared between groups. The median fibroid ablation rates were similar in the scar and non-scar groups: 87.81% (IQR 78.20-98.80%) and 87.67% (IQR 75.18-96.75%), respectively ( p = 0.403). The incidence of skin-burning sensation during operation in the scar group was significantly higher than that in the non-scar group [15.96% (34/213) vs 8.35% (33/395), p = 0.004]. Postoperative abdominal wall MRT2WI signal changes occurred in 22.37% (136/608) of cases, mainly in the subcutaneous fat layer (50%, 68/136), appearing as patchy mixed high signal on MRT2WI. These changes were higher in the scar group than in the non-scar group [28.17% (60/213) vs 19.24% (76/395), p = 0.012]. However, these abnormalities resolved spontaneously without intervention. No serious adverse events or complications occurred in either group during or after treatment. Abdominal wall surgical scars on the acoustic pathway do not significantly affect the safety and efficacy of USgHIFU for uterine fibroids.

To investigate the association between congenital uterine anomalies (CUAs) and placenta accreta spectrum (PAS), and to explore obstetric outcomes following hysteroscopic septal resection. This retrospective cohort study included singleton pregnancies delivered at ≥22 weeks of gestation at a tertiary referral center between 2013 and 2024. PAS was diagnosed based on the 2019 International Federation of Gynecology and Obstetrics (FIGO) clinical or pathological criteria. The association between CUAs and PAS was evaluated using Firth's penalized logistic regression analysis. Sensitivity analyses were additionally performed using conventional logistic regression models. Obstetric outcomes following hysteroscopic septal resection were descriptively analyzed. Among 2,891 pregnancies, 31 (1.1%) involved CUAs, including 11 pregnancies following hysteroscopic septal resection. PAS occurred more frequently in the CUA group than in the non-CUA group (9.7% vs. 1.3%, p < 0.01). Firth's penalized logistic regression showed that CUAs were significantly associated with PAS (crude odds ratio [OR], 9.25; 95% confidence interval [CI], 2.42-26.1; p < 0.01). After adjustment for placenta previa or low-lying placenta, the association became stronger (adjusted OR, 21.8; 95% CI, 5.47-67.0; p < 0.001). Sensitivity analyses adjusting for advanced maternal age, assisted reproductive technology, and previous cesarean delivery showed consistent results. Cesarean delivery was significantly more common in pregnancies complicated by CUAs. In an exploratory descriptive analysis, no PAS cases were observed among following septal resection. CUAs may be a potential risk factor for PAS. In contrast, our exploratory analysis did not identify PAS cases following hysteroscopic septal resection. Large-scale multicenter studies using PAS defined according to the diagnostic criteria proposed by FIGO are essential to validate these findings and clarify the underlying mechanisms.

To investigate the predictive value of the cerebroplacental-uterine ratio (CPUR) combined with multiple ultrasound parameters for adverse perinatal outcomes (APOs) in late-onset fetal growth restriction (FGR). This retrospective study included 149 singleton pregnant women diagnosed with suspected late-onset FGR at our hospital from August 2023 to January 2025. Based on perinatal outcomes, they were divided into a non-adverse outcome group (105 cases) and an adverse outcome group (44 cases). Ultrasound parameters including umbilical artery pulsatility index (UA-PI), middle cerebral artery pulsatility index (MCA-PI), uterine artery pulsatility index (UtA-PI), cerebroplacental ratio (CPR), CPUR, aortic isthmus pulsatility index (AoI-PI), and estimated fetal weight (EFW) percentile were measured and compared between the two groups. Univariate analysis was used to screen significant variables, followed by binary logistic regression analysis to identify independent predictors. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of individual indicators and combined models. The adverse outcome group had significantly higher levels of UA-PI, UtA-PI, AoI-PI, and a higher proportion of EFW <5th percentile compared to the non-adverse outcome group, while MCA-PI, CPR, and CPUR levels were significantly lower (all p < 0.001). Multivariate regression analysis showed that CPUR (OR = 0.061, 95% CI: 0.021-0.172), AoI-PI (OR = 14.003, 95% CI: 3.928-49.925), and EFW <5th percentile (OR = 3.386, 95% CI: 1.124-10.193) were independent predictors of APOs in late-onset FGR. ROC curve analysis revealed that the combined prediction model incorporating CPUR, AoI-PI, and EFW (<5th) had the best predictive performance, with an AUC of 0.932 (95% CI: 0.890-0.974), sensitivity of 84.1%, and specificity of 86.7%, outperforming any single indicator. CPUR, AoI-PI, and EFW (<5th) are independent predictors of APOs in late-onset FGR. The combined prediction model constructed from these three parameters demonstrates high predictive value and may provide a reference for early identification of high-risk fetuses and optimization of perinatal management.

High-intensity focused ultrasound (HIFU) therapy is increasingly used in the management of various solid tumors. However, limited data are available regarding the association between HIFU treatment and coagulation function. A total of 1,189 patients diagnosed with uterine fibroids or adenomyosis who underwent HIFU therapy at Shanghai First Maternal and Infant Hospital between August 2015 and November 2020 were included. Paired t-tests were conducted to compare coagulation indicators measured before and after HIFU treatment. Multiple logistic regression models were used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) to evaluate the association between the risk of elevated D-dimer/fibrinogen degradation products (FDP) and HIFU treatment parameters categorized into tertiles. A total of 1,148 eligible patients were included in the final analysis. After HIFU treatment, 61.8% and 55.7% of patients showed elevated D-dimer and FDP levels, respectively, and 54.6% exhibited simultaneous elevation of both on the first day after treatment. Other post-treatment coagulation indicators also demonstrated a hypercoagulable state, including prolonged prothrombin time and thrombin time, shortened activated partial thromboplastin time, and decreased platelet count. During follow-up, no patients developed thromboembolism. Several HIFU parameters were associated with increased D-dimer and FDP levels. The highest tertile of exposure energy was significantly associated with a greater risk of simultaneous elevation of both D-dimer and FDP (adjusted OR [95% CI]: 4.58 [3.17, 6.66]). Higher exposure energy during HIFU treatment may induce alterations in coagulation function, resulting in a transient post-treatment hypercoagulable state.

Villamonte-Calanche, Wilfredo, Marco Antonio Salazar-Zegarra, Franklin Miranda-Solis, and María Jerí-Palomino. Correlation of uterine blood flow in the first trimester of pregnancy and birth weight at term in high altitude. High Alt Med Biol. 27:239-244, 2026. To determine the correlation between total uterine artery flow (UtAQ) at the end of the first trimester of pregnancy and birth weight (BW) at term at 3,400 m altitude. Prospective study, conducted at 3,400 m altitude in 210 women who underwent routine ultrasound evaluation. The inclusion criteria were singleton pregnancy between 11 and 14 weeks + 1 day, crown-rump length between 45 and 84 mm, born and raised at high altitude (native), and without pathology. The outcome was BW, expressed as a Z score. Variables such as UtAQ, uterine artery (UtA) diameters, age, body mass index, and mean arterial pressure, among others, were evaluated. After applying the inclusion criteria, 203 pregnant women were evaluated, out of a total of 210 women. The average diameter of UtA was 0.27 cm, and the total bilateral UtA blood flow was 305.8 ml/min. A significant correlation was found between BW and UtAQ (rho = 0.15, p = 0.033), with a higher association for the left UtA (rho = 0.19, p = 0.007). Similarly, BW was positively correlated with the average diameter of the UtAs (r = 0.21, p = 0.003) and the association was stonger for the left UtA (r = 0.19, p = 0.006). In low-risk singleton pregnancies among native women living at high altitude, a correlation was observed between UtAQ and term BW, with the highest association found between BW and the diameter and UtAQ of the left UtA.

Refractory and recurrent uterine fibroids present complex therapeutic challenges, particularly in patients who desire fertility preservation. Clinical management must balance multiple competing risks: preserving reproductive potential, preventing oestrogen-stimulated regrowth during assisted reproduction, and avoiding complications from repeated surgical interventions. We report a challenging case of a woman with multiple recurrent refractory uterine fibroids and associated infertility. The patient underwent two prior open myomectomies followed by four sessions of high-intensity focused ultrasonography. Due to inadequate response, subsequent combination therapy included ultrasound-guided absolute ethanol injection into the residual perfused fibroid tissue and three months of gonadotropin-releasing hormone agonist administration. Pregnancy was ultimately achieved through in vitro fertilization embryo transfer. Following the combined treatment approach, the patient successfully conceived and delivered a healthy newborn. This case suggests that for patients with difficult-to-treat, recurrent uterine fibroids, a multimodal strategy combining serial high-intensity focused ultrasound procedures with adjuvant gonadotropin-releasing hormone agonist therapy may facilitate favorable reproductive outcomes. Although the evidence continues to evolve, this successful live birth offers clinical support for the use of this integrated approach in selected cases.