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Background: Postpartum hemorrhage (PPH), a serious labor-related complication, is the leading cause of maternal mortality, which requires an emergent intervention. Uterine arterial embolization (UAE) is an effective treatment for hemostasis of intractable PPH. Several risk factors have been reported for the failure of UAE. Objectives: To evaluate the clinical outcomes of UAE for the treatment of primary PPH following cesarean section (CS) and to determine the risk factors associated with the failure of this procedure. Patients and Methods: This retrospective, single-center study was approved by the institutional review board, and the requirement to obtain informed consent was waived. All patients referred to a tertiary care center, who underwent UAE for primary PPH between January 2018 and December 2020, were included. The patients’ medical records and radiological findings, including the patients’ characteristics, mode of delivery, initial vital signs and laboratory findings after hospitalization, procedure details, and embolization outcomes, were evaluated for data collection. Technical success was defined as appropriate embolization of target vessels on a completion angiogram. Clinical success was defined as adequate cessation of bleeding after the first embolization, without any need for subsequent embolization or surgical intervention. Statistical analysis was performed to determine factors related to the clinical failure of UAE in CS cases. Results: UAE was performed for 25 patients (mean age, 37.2 years; range, 25 - 45 years). The technical success rate was estimated at 100% (n = 25), and the clinical success rate was 76% (n = 19). There were no patients with permanent adverse sequelae or death. The univariate analyses showed that hemodynamic instability (P = 0.006), lower hemoglobin levels (P = 0.02), and prolonged activated partial thromboplastin time (aPTT) (P = 0.017) were related to clinical failure. The logistic regression analysis adjusted for age showed that the area under the curve (AUC) was 0.86 for hemoglobin (95% CI: 0.7 - 1; cutoff value: 0.667), 0.816 for aPTT (95% CI: 0.625 - 1; cutoff value: 0.411), and 0.868 for hemodynamic instability (95% CI: 0.661 - 1; cutoff value: 0.622). Conclusion: UAE is a safe and effective treatment for primary PPH following CS. Hemodynamic instability, low hemoglobin levels, and prolonged aPTT can be predictive factors for the poor outcomes of UAE in CS patients. These factors are rapid and straightforward criteria, which can be simply applied, even in emergency situations.

The electronic structure of aluminum tris-8-hydroxyquinoline (Alq3) and 8-hydroquinolatolithium (Liq) was investigated using a combination of X-ray emission spectroscopy (XES), X-ray absorption spectroscopy (XAS), X-ray photoelectron spectroscopy (XPS), and spectral simulation with density functional theory. The chemical bonding states of Alq3 and Liq were analyzed using XPS core-level spectra. The band gaps of Alq3 and Liq were measured by combining the XAS and XES results. Additionally, resonant and non-resonant XES were used to measure the density of states for O sites in the molecules.

Background A heterogeneous radiological response is frequently observed in cancer patients and could reflect tumor heterogeneity. We investigated the prognostic impact of heterogeneous radiological responses in patients with advanced non‐small‐cell lung cancer (NSCLC) who received platinum‐based chemotherapy. Methods The treatment response according to Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria was evaluated in 212 patients with advanced NSCLC who received platinum‐based chemotherapy. Patients with partial response (PR) or stable disease (SD) were classified into “PR homo,” “PR hetero,” “SD homo,” and “SD hetero” by the presence of a heterogeneous radiological response, and survival was compared between groups. We also compared survival based on the presence of metabolic responses in lesions with heterogeneous radiological responses. Results Fifty‐two patients (24.5%) were classified as PR, 112 patients (52.8%) as SD, and 48 patients (22.7%) as progressive disease (PD). There was no significant difference in progression‐free survival (PFS) and overall survival (OS) between the PR homo and PR hetero groups. The SD homo group had a longer PFS and OS than the SD hetero group. In the SD hetero group, patients with increased maximum standardized uptake value (SUVmax) in lesions with heterogeneous radiological responses had a shorter PFS than those with a stable SUVmax. Conclusions The presence of lesions with radiological heterogeneity was associated with disease progression and poor prognosis in the SD group. Patients with heterogeneous radiological responses require careful monitoring., Patients with heterogeneous radiological responses in the SD group had a shorter PFS and OS. In particular, patients with increased SUVmax in lesions with heterogeneous radiological responses had a shorter PFS than patients with a stable SUVmax. The presence of lesions with radiological heterogeneity was associated with disease progression and poor prognosis in the SD group.

Crizotinib is an oral selective small-molecular tyrosine kinase inhibitor (TKI) that suppress the activity of anaplastic lymphoma kinase (ALK) and ROS1 kinases, as well as mesenchymal-epithelial transition. The cumulative clinical trials in patients with advanced ALK- or ROS1-rearrangement NSCLC indicate that crizotinib has significant antitumor activity and a tolerable safety profile, with mild or moderate adverse events of visual disorders, diarrhea, nausea, and vomiting. As with other TKIs, however, the occurrence of crizotinib-related interstitial lung disease (crizotinib-ILD) remains a major clinical dilemma that can lead to the permanent discontinuation of TKI during cancer treatment. When there is no suitable alternative therapy for patients who develop crizotinib-ILD, some clinicians have reported successful crizotinib retreatment in cases of ALK-rearrangement NSCLC. Unfortunately, there are no specific guidelines for the treatment or retreatment of TKI-related ILD. We herein report the first successful crizotinib retreatment after crizotinib-ILD in a patient with ROS1-rearranged NSCLC, and suggest a retreatment strategy after crizotinib-ILD based on a literature review.

Cholesterol is essential for neuronal activity and function. Cholesterol depletion in the plasma membrane impairs synaptic transmission. However, the molecular mechanisms by which cholesterol deficiency leads to defects in vesicle fusion remain poorly understood. Here we show that cholesterol is required for Ca2+-dependent native vesicle fusion using the in-vitro reconstitution of fusion and amperometry to monitor exocytosis in chromaffin cells. Purified native vesicles were crucial for the reconstitution of physiological Ca2+-dependent fusion, whereas vesicle-mimicking liposomes failed to reproduce the cholesterol effect. Intriguingly, cholesterol had no effect on membrane binding of synaptotagmin-1, a Ca2+ sensor for ultrafast fusion. Cholesterol stabilizes local membrane bending induced by synaptotagmin-1, thereby lowering the energy barrier for Ca2+-dependent fusion to occur. Our data provide evidence that cholesterol depletion abolishes Ca2+-dependent vesicle fusion by disrupting synaptotagmin-1-induced membrane bending, and suggests that cholesterol is an important lipid regulator for Ca2+-dependent fusion.

This study sought to investigate the dietary life of adolescents according to their household types and factors that could affect their health status using the raw data of the Korea National Health and Nutrition Examination Survey (2016-2018). 160 adolescents aged 13-18 in single parent households (SPH) and parents households (PH) respectively were analyzed. The ratio of SPH to the income quartile ‘high’ was 55%, but only 18.1% of SPH in ‘low’ and ‘middle-low’ was 59.4%. It was found that there was a difference between the subjective body type recognition and the actual body type. There was a significant difference in the rate of missing breakfast, 20.0% in SPH, as compared to 8.8% in PH. According to an analysis of the ratio of actual intake to the recommended nutrient intake, all subjects were found to have less than 100 percent recommended intake of energy, vitamin A, niacin, vitamin C, calcium, phosphorus, iron, dietary fiber, and potassium. An analysis of the effect of food intake on health indicators showed that grain and condiment intake affected fasting plasma glucose, HDL cholesterol, and systolic blood pressure, grain and processed food intake affected waist circumference, grain and alcohol intake affected triglycerides, and grain and beverage intake affected systolic blood pressure. In SPH, grain and processed foods were found to affect waist circumference, fasting plasma glucose, HDL cholesterol, and blood pressure. Also, grain and beverage intake affected triglyceride levels.

p19arf, primarily known as a tumor suppressor, has also been reported to play an essential role in normal development of mouse eyes. Consistently, lack of p19arf has been associated with ocular defects, but the mixed background of the knockout (KO) mouse strain used raised a concern on the accuracy of the phenotypes observed in association with the targeted gene due to genetic heterogeneity. We carried out a study to investigate into the effect of genetic background on the manifestation of p19arf KO associated phenotypes. We characterized the phenotypes of novel p19arf KO mouse lines generated in FVB/N and C57BL/6J using a transcription activator-like effector nuclease (TALEN) system in comparison to the reported phenotypes of three other p19arf-deficient mouse lines generated using homologous recombination. Ninety-five percent of FVB/N-p19arf KO mice showed ocular opacity from week 4 after birth which worsened rapidly until week 6, while such abnormality was absent in C57BL/6J-p19arf KO mice up to the age of 26 weeks. Histopathological analysis revealed retrolental masses and dysplasia in the retinal layer in FVB/N-p19arf KO mice from week 4. Besides these, both strains developed normally from birth to week 26 without increased tumorigenesis except for a subcutaneous tumor found in a C57BL/6J-p19arf KO mouse. Our findings demonstrated surprisingly variable manifestation of p19arf-linked phenotypes between FVB/N and C57BL/6J mice, and furthermore between our mouse lines and the established lines, indicating a critical impact of genetic background on functional study of genes using gene targeting strategies in mice.

The condensin SMC protein complex organizes chromosomal structure by extruding loops of DNA. Its ATP-dependent motor mechanism remains unclear but likely involves steps associated with large conformational changes within the ∼50 nm protein complex. Here, using high-resolution magnetic tweezers, we resolve single steps in the loop extrusion process by individual yeast condensins. The measured median step sizes range between 20–40 nm at forces of 1.0–0.2 pN, respectively, comparable with the holocomplex size. These large steps show that, strikingly, condensin typically reels in DNA in very sizeable amounts with ∼200 bp on average per single extrusion step at low force, and occasionally even much larger, exceeding 500 bp per step. Using Molecular Dynamics simulations, we demonstrate that this is due to the structural flexibility of the DNA polymer at these low forces. Using ATP-binding-impaired and ATP-hydrolysis-deficient mutants, we find that ATP binding is the primary step-generating stage underlying DNA loop extrusion. We discuss our findings in terms of a scrunching model where a stepwise DNA loop extrusion is generated by an ATP-binding-induced engagement of the hinge and the globular domain of the SMC complex.

The major sites of metastasis in non-small cell lung cancer (NSCLC) are bones, the brain, adrenal glands, the liver, the contralateral lung, and distant lymph nodes. Solitary metastasis in an uncommon site is very rare; therefore, it has not often been reported. Identifying whether a solitary lesion is a metastatic lesion is important because it decisively influences the stage and treatment decisions. We report a series of cases of NSCLC diagnosis with uncommon solitary metastasis. (1) A 71-year-old man was diagnosed with poorly differentiated NSCLC after a bronchoscopic biopsy of a tumor in the bronchus of the right middle lobe. A hypermetabolic lesion was observed in the tail of the pancreas using positron emission tomography/computed tomography (PET/CT), and metastasis of NSCLC was confirmed using endoscopic ultrasound fine-needle aspiration (EUS-FNA). (2) A 77-year-old man was diagnosed with squamous cell carcinoma after a bronchoscopic biopsy of a tumor in the bronchus of the left upper lobe. A hypermetabolic lesion was observed in the bilateral lobes of the thyroid gland using PET/CT, and metastasis of the squamous cell carcinoma was confirmed by FNA and cytology. (3) A 79-year-old woman was diagnosed with adenocarcinoma by brushing cytology performed on the apicoposterior segmental bronchus of the left upper lobe. Hypermetabolic lesions were observed using PET/CT in the subcutaneous layer of the right back and the left breast, and metastases of adenocarcinoma were confirmed by biopsies in each lesion. These three patients were treated with platinum-based chemotherapy for stage IV lung cancer. With this case series, we recommend that, when a solitary lesion is observed in NSCLC patients, a tissue biopsy should be performed, even if the lesion is located in an organ where lung cancer metastasis is uncommon.

Future time perspective, like self-efficacy, can be understood both generally and domain specifically. Keeping this in mind, the current study aimed at developing and validating a Career Future Time Perspective Scale. In Study 1, we utilized an exploratory factor analysis and the Rasch rating model to ensure the construct validity of a Career Future Time Perspective Scale. The scale consisted of three factors—opportunity, value, and connectedness—across 9 items. In Study 2, we showed that this three-factor oblique scale was the most representative structure of career future time perspective. Study 3 demonstrated that after controlling for the future time perspective measures posited by Shell and Husman and Carstensen and Lang, this scale could also be used to explain: (a) career decision-making self-efficacy, (b) career-indecision tendencies, and (c) career-searching behavior. In Study 4, the reliability of the scale was demonstrated.

The cumulative results indicate that the neutrophil to lymphocyte ratio of peripheral blood (pbNLR) is a useful prognostic factor in patients with various cancers. In contrast to peripheral blood, the bronchoalveolar lavage (BAL) fluid is in direct contact with the lung lesion. However, no study has reported on the clinical utility of the NLR of BAL fluid (bNLR) for patients with lung cancer. To investigate the clinical utility of the bNLR as a prognostic factor in patients with lung cancer, we conducted a retrospective review of the prospectively collected data. A total of 45 patients were classified into high bNLR (n = 29) and low bNLR (n = 16) groups. A high pbNLR and high bNLR were associated with a shorter overall survival (p < 0.001 and p = 0.011, respectively). A multivariable analysis confirmed that ECOG PS (p = 0.023), M stage (p = 0.035), pbNLR (p = 0.008), and bNLR (p = 0.0160) were independent predictors of overall survival. Similar to the pbNLR, a high bNLR value was associated with a poor prognosis in patients with lung cancer. Although further studies are required to apply our results clinically, this is the first study to show the clinical value of the bNLR in patients with lung cancer.

The ring-shaped structural-maintenance-of-chromosomes (SMC) complexes condensin and cohesin extrude loops of DNA as a key motif in chromosome organization. It remains, how ever, unclear how these SMC motor proteins can extrude DNA loops in chromatin that is bound with proteins. Here, using in vitro single-molecule visualization, we show that nucleosomes, RNA polymerase, and dCas9 pose virtually no barrier to DNA loop extrusion by yeast condensin. Strikingly, we find that even DNA-bound nanoparticles as large as 200 nm, much bigger than the SMC ring size, can be translocated into DNA loops during condensin-driven extrusion. Similarly, human cohesin can pass 200 nm particles during loop extrusion, which even occurs for a single-chain version of cohesin in which the ring-forming subunits are covalently linked and cannot open up to entrap DNA. These findings disqualify all common loop-extrusion models where DNA passes through the SMC rings (pseudo)topologically, and instead point to a nontopological mechanism for DNA loop extrusion.One-sentence summaryHuge DNA-bound roadblocks can be incorporated into SMC-extruded DNA loops, pointing to a nontopological mechanism for loop extrusion.

In order to maximize the efficiency of the limited resources for fire-fighting and prevention, it is important to set a forest fire precaution period by considering the temporal characteristics of forest fire occurrence and spread. In this study, the forest fire precaution periods were suggested based on statistical analysis of the national fire statistics data from 1991 to 2018. Multiple, ridge, and Lasso regression analyses were applied to identify the monthly (or 10 days) linear trend of fire occurrences, while k-means cluster analysis was used to select the precaution period. The fire occurrences in January, June, August and November have increased significantly over time, whilst those in March, April and May remained high without fluctuation over this period. The results suggest the extension of the fire precaution period in South Korea from 5 months (Spring: February 1 to May 15, Autumn: November 1 to December 15) to 8 months from mid-October to mid-June. This results from this study are expected to serve as statistical evidence for readjustment of forest fire precaution period in South Korea.

In this paper, a miniaturization methodology of protective devices (PDs) was proposed which plays a key role in evaluating the effectiveness of the developed protection and control algorithms in the micro smart grid simulator. The micro PD was designed to have the rated voltage of 19 V and the breaking current of 20 A, and was designed in a multi-layered hardware structure to satisfy the size of 13 × 13 cm2. Also, the micro PD was designed in a multifunctional structure to allow one micro PD to perform all the functions of the circuit breaker, recloser and switches on the micro smart grid simulator to enhance the efficiency of development. Finally, it was verified that the developed micro PD can be applied as protective devices of the micro smart grid simulator by showing that it operates correctly according to the predetermined operation sequence for the test scenarios on the built test system.

항공여객시장은 지속적인 성장을 하고 있으며 특히 대형항공사와 저비용항공사의 경쟁이 날로 격화되어가고 있다. 이러한 시점에서 대형항공사는 저비용항공사에 대한 차별적 경쟁우위를 유지하고 강화하는 것이 특히 중요하다. 기내식은 저비용항공사와 비교하였을 때 대형항공사의 차별적 경쟁우위의 요소가 될 수 있어 이에 대한 연구가 필요하다. 이에 본 연구는 기내식 품질과 만족에 영향을 미치는 요소가 무엇인지, 그리고 기내식이 기내 서비스, 항공사 이미지, 가격 민감도 및 재이용 의도에 미치는 영향관계를 실증적으로 분석하고자 한다. 본 연구에서는 항공사 이용 경험이 있는 고객을 대상으로 설문지 318부를 통해 자료를 수집하였으며 구조모형방정식을 통하여 변수간의 관계를 분석하였다. 분석 결과, 승무원 서비스 환경이 기내식 품질 인식에 영향을 미쳤으며, 기내식 만족은 기내 서비스 만족과 항공사 이미지 향상에 영향을 미쳤다. 또 이는 가격민감도를 완화하고 재이용 의도를 증가시키는 것으로 나타났다. 즉, 대형항공사는 양질의 기내식 제공으로 항공사 서비스와 이미지를 개선할 수 있으며 이를 통해 저비용항공사와 비교되는 항공권 가격에 대한 민감도를 완화할 수 있으며 계속적인 이용을 유도할 수 있다는 실무적 시사점을 발견하였다.

Circulating tumor DNA (ctDNA) has been utilized to monitor the clinical course of patients of non-small-cell lung cancer (NSCLC) who receive therapies targeting druggable mutations. However, despite providing valuable information on how NSCLC would naturally progress, the clinical utility of ctDNA for clinical-course monitoring and prediction of treatment-naïve NSCLC patients without druggable mutations remain unknown. We longitudinally followed a total of 12 treatment-naïve NSCLC patients, who did not harbor EGFR and ALK mutations, by collecting clinical information, radiological data, and plasma samples. Changes in ctDNA levels and tumor burden (TB) were compared with each other. New metastasis development, volume doubling time (VDT), and overall survival (OS) were analyzed regarding ctDNA detection at diagnosis. ctDNA was detected in the plasma of seven (58.3%) patients. Changes in ctDNA levels correlated with those in TB in a substantial fraction (57.1%) of patients and was also associated with brain metastasis, tumor necrosis, or pneumonia in other patients. All patients with ctDNA detection developed new metastasis during follow-ups in the organs that had been devoid of metastasis at diagnosis. The patients without ctDNA detection did not develop new metastasis (median duration of follow-ups: 9.8 months). In addition, patients with ctDNA detection had shorter VDT (p = 0.039) and worse OS (p = 0.019) than those without ctDNA detection. The natural course of NSCLC progression can be monitored by measuring ctDNA levels. Detection of ctDNA at diagnosis can predict development of new metastasis, rapid tumor growth and poor survival of NSCLC patients.

Recombination activating gene-2 (RAG-2) plays a crucial role in the development of lymphocytes by mediating recombination of T cell receptors and immunoglobulins, and loss of RAG-2 causes severe combined immunodeficiency (SCID) in humans. Rag-2 knockout mice created using homologous recombination in ES cells have served as a valuable immunodeficient platform, but concerns have persisted on the specificity of Rag-2-related phenotypes in these animals due to the limitations associated with the genome engineering method used. To precisely investigate the function of Rag-2, we recently established a new Rag-2 knockout FVB mouse line (Rag-2-/-) manifesting lymphopenia by employing a CRISPR/Cas9 system at Center for Mouse Models of Human Disease. In this study, we further characterized their phenotypes focusing on histopathological analysis of lymphoid organs. Rag-2-/- mice showed no abnormality in development compared to their WT littermates for 26 weeks. At necropsy, gross examination revealed significantly smaller spleens and thymuses in Rag-2-/- mice, while histopathological investigation revealed hypoplastic white pulps with intact red pulps in the spleen, severe atrophy of the thymic cortex and disappearance of follicles in lymph nodes. However, no perceivable change was observed in the bone marrow. Moreover, our analyses showed a specific reduction of lymphocytes with a complete loss of mature T cells and B cells in the lymphoid organs, while natural killer cells and splenic megakaryocytes were increased in Rag-2-/- mice. These findings indicate that our Rag-2-/- mice show systemic lymphopenia with the relevant histopathological changes in the lymphoid organs, suggesting them as an improved Rag-2-related immunodeficient model.

Background and Purpose— Acceleration of longitudinal relaxation under hyperoxic challenge (ie, hyperoxia-induced ΔR 1 ) indicates oxygen accumulation and reflects baseline tissue oxygenation. We evaluated the feasibility of hyperoxia-induced ΔR 1 for evaluating cerebral oxygenation status and degree of ischemic damage in stroke. Methods— In 24-hour transient stroke rat models (n=13), hyperoxia-induced ΔR 1 , ischemic severity (apparent diffusion coefficient [ADC]), vasogenic edema (R 2 ), total and microvascular blood volume (superparamagnetic iron oxide-driven ΔR 2 * and ΔR 2 , respectively), and glucose metabolism activity ( 18 F-fluorodeoxyglucose uptake on positron emission tomography) were measured. The distribution of these parameters according to hyperoxia-induced ΔR 1 was analyzed. The partial pressure of tissue oxygen change during hyperoxic challenge was measured using fiberoptic tissue oximetry. In 4-hour stroke models (n=6), ADC and hyperoxia-induced ΔR 1 was analyzed with 2,3,5-triphenyltetrazolium chloride staining being a criterion of infarction. Results— Ischemic hemisphere showed significantly higher hyperoxia-induced ΔR 1 than nonischemic brain in a pattern depending on ADC. During hyperoxic challenge, ischemic hemisphere demonstrated uncontrolled increase of partial pressure of tissue oxygen, whereas contralateral hemisphere rapidly plateaued. Ischemic hemisphere also demonstrated significant correlation between hyperoxia-induced ΔR 1 and R 2 . Hyperoxia-induced ΔR 1 showed a significant negative correlation with 18 F-fluorodeoxyglucose uptake. The ADC, R 2 , ΔR 2 , and 18 F-fluorodeoxyglucose uptake showed a dichotomized distribution according to the hyperoxia-induced ΔR 1 as their slopes and values were higher at low hyperoxia-induced ΔR 1 (−1 ) than at high ΔR 1 . In 4-hour stroke rats, the distribution of ADC according to the hyperoxia-induced ΔR 1 was similar with 24-hour stroke rats. The hyperoxia-induced ΔR 1 was greater in the infarct area (47±10 ms −1 ) than in peri-infarct area (16±4 ms −1 ; P Conclusions— Hyperoxia-induced ΔR 1 adequately indicates cerebral oxygenation and can be a feasible biomarker to classify the degree of ischemia-induced damage in neurovascular function and metabolism in stroke brain.

In September 2018, an outbreak of Listeriosis cases in Korea was traced to food involved, using retrospective cohort studies and PFGE analyses. This study aimed to describe the first L.monocytogenes outbreak identified in Korea. We confirmed the presence of Serovar (4C) and virulence genes, and evaluated the genetic correlation between isolates by restriction digestion patterns of ApaI and AscI. Based on the epidemiological association, it is presumed that the seasoned crab meat with bean sprouts are contaminated by cross contamination during the bean sprouts washing (relative risk was 1.24; p-value: 0.0021 and they possessed virulence genes. Therefore, active laboratory surveillance is necessary to recognize the risk of L. monocytogenes in Korea.

Introduction Sonography and magnetic resonance imaging (MRI) may be helpful to obtain an accurate diagnosis of acute abdominal pain in pregnancy. Adnexal torsion presenting in the first or second trimester can be confirmed and treated through laparoscopic surgery; however laparoscopic surgery in the third trimester can be difficult owing to the large uterus, and a gridiron incision can be useful. Case Report/Case presentation An 18-year-old gravida 1, para 0 (G1P0) woman at 30 + 4 weeks of gestation presented with sudden-onset cyclic pain in the right lower quadrant. Abdominal ultrasonography showed a normal appendix, and MRI showed a normal appendix and normal ovaries. The patient’s prominent tender point was marked and compared with the MR images, which confirmed the mark as the position of the right ovary. Laparotomy was performed through a gridiron incision, and a folded right ovary was identified. The ovary was unfolded, and TachoSil® and Surgicel® were used to maintain the unfolded position. The patient’s pain resolved, and her postoperative course was uneventful. She delivered a healthy, 2540-g male baby at 35 weeks’ gestation. Discussion/Conclusions A gridiron incision was useful to treat a folded ovary in the third trimester and to evaluate the adnexa and minimize uterine manipulation.