馬偕 劉天仁+英濟 開發 耳部解剖模型

馬偕醫院/英濟合作耳部解剖模型，獲發明展金牌獎 MoneyDJ新聞 2015-10-07 06:20:18 記者 蕭燕翔 報導 跨足醫學教學零件領域，塑件廠 與微投影的技術，開發出可運用於醫學教育與訓練的首個成品，英濟也期許，未來能拓展其他醫學教學應用的零件開發。該技術的原始發明人為劉天仁，並獲得馬偕醫院育成中心的支持，生產則委由英濟負責。相較於傳統耳道教學模型擬真效果不佳的弊端，此次設計生產的新品，著重於互動式教學，並由三個主要技術構成，分別為遠端控制系統、光機微投影系統及擬真人頭與耳道模型，其中遠端控制系統用於影像輸入與資料庫編輯與儲存，光機微投影系統負責影像輸出，擬真人頭與耳道模型則用在教學上的病理檢查與檢耳鏡操作訓練。 此也是結合英濟過去在塑件射出成型與微投影的技術能力，並開發出首個應用於醫學教學的成品，未來可望用於醫學教學中心，該公司期許，未來能有機會擴及其他科別醫學教學上的零件開發。

台灣精準醫療典範: allopurinol藥物 & HLA-B*58:01基因檢測

基因篩檢 可預防痛風藥物副作用 2015-10-21 13:26:08 聯合報 記者鄧桂芬╱即時報導部分痛風病人服藥後，引發嚴重皮膚過敏。中研院與台北榮總等16家醫院共同研究，發現痛風藥物allopurinol誘發過敏，和病患的HLA-B*58:01基因高度相關，病人在服藥前做好基因篩檢，基因呈現陽性患者避免服藥，改以其他替代藥物治療，就能有效預防嚴重副作用。這項研究成果，已在9月23日刊登國際英國醫學期刊。中央研究院生醫所教授沈志陽表示，醫學界廣泛使用的allopurinol藥物，用來治療痛風或降尿酸，有些患者服用後，會引發嚴重的皮膚過敏（SCARs）。為了找出預防嚴重副作用的方法，研究團隊2005年中研院生醫所研究發現，使用allopurinol後，誘發嚴重過敏的情況，與病患的HLA-B*58:01基因型，有高度相關為基礎，將HLA-B*58:01基因檢測應用於臨床。國內約3000名服用allopurinol藥物的痛風病患，進行用藥前基因測試，當HLA-B*58:01基因檢測為陰性的病患，可繼續用藥，至於檢測出陽性的患者，建議避免服用這種藥物，改以替代藥物進行治療。研究結果顯示，所有參與研究的病患在追蹤觀察兩個月內，均無皮膚過敏發生，證實用藥前做基因篩檢，能有效預防皮膚藥物過敏發生。台北榮總過敏免疫風濕科主任蔡長祐表示，站在藥害防治角度，若能將基因檢測當作服用allopurinol藥物前的常規檢查，可大幅提升國人用藥安全，而這項研究將帶領台灣進入精準化醫療先進國家。

攬 邱文達 任 上海悅心健康醫顧董事長! 雙連安養中心(三芝淺水灣)

雙連安養中心西進　結盟上海台商斯米克 邱文達加持　新經營團隊來頭大要排到5000多號才能入住的台灣雙連安養中心，近期與上海斯米克控股合作， 西進中國大健康產業，執行長蔡芳文不藏私，大方分享輸出養老機構管顧經驗。2015/10/21 出處：財訊雙週刊 第 488 期 作者：洪綾襄8月初，有地磚大王之稱的上海老牌台資企業斯米克控股公布重大訊息，宣布集團大幅度轉型，進入以養老與醫療為核心的大健康產業，公司則更名為「上海悅心健康集團股份有限公司」。但更引起兩岸醫界熱議的，是轉型後的新經營團隊名單。悅心健康不但延攬了台灣衛福部前部長邱文達擔任子公司悅心健康醫療管理顧問公司董事長，台灣最負盛名的雙連安養中心執行長蔡芳文也赫然名列其中，將擔任悅心養老事業總顧問。根據估計，儘管台灣人口老化速度較快，在2025年就會進入超高齡社會（65歲人口占總人口2成以上），但由於中國大陸人口眾多，又長期實施一胎化政策，未來面臨高齡化的挑戰將比台灣更為嚴峻；而台灣的健康、醫療、養老產業資源以及優質醫療服務便成為中國取經的對象，悅心健康也希望藉醫療與養老兩大引擎，一舉成為兩岸中高端家庭健康醫護的首選品牌。

地磚大王　跨足健康產業 新經營團隊都是兩岸政界與商界知名人士。斯米克董事長李慈雄其實背景顯赫，岳父為早期軍政界聞人蕭政之；身為最早進入上海浦東墾荒的台商，李慈雄也是國學大師南懷瑾的關門弟子。斯米克控股在中國的事業除了地磚，也涵蓋造紙（華潔紙業）、鋰電池（鋰曜能源）、房地產（美加置業）、教育（武漢外國語學校），企業版圖龐大。相較之下，雙連安養中心不過是新北市一家規模不到500床的養老院，卻具有與他們平起平坐的實力，「其實我們就只是把6個字做好：符合老人需求，」雙連安養中心執行長蔡芳文笑著說。在台灣長照業界，雙連安養中心締造了一個傳奇：「想住？得等80年！」原為台北市雙連長老教會自發開辦的非營利單位，雙連安養中心成立十五年來從不花錢打廣告行銷，但靠著服務與教友口碑，自營運第4年起進住率便達到100分之100，更屢屢在全台灣1000多家老人照護機構中，獲第1名評比，至今排隊等著入住的人已排到5000多。曾有媒體粗估，若按照排隊順序，現在才登記的恐怕要等80年才住得進去。因此已有不少40、50歲的中壯年人已提早登記床位，預約晚美人生。在台灣把安養中心經營到人人搶，如今更被邀請西進中國，區區一個非營利的財團法人怎麼辦到的？

想住雙連養老　得等80年 在一個細雨綿綿的午後，記者來到位於三芝淺水灣一探究竟。走進背山面海的雙連安養中心園區，首先會被充滿現代感的銀白色禮拜堂吸引目光，中心的接待廳小巧雅致，沒有大財團打造養生村所訴求的五星級氣派豪華，但卻顯得更舒適愜意，因為雖然雙連看似無異於一般養老院，但其實每一個細節均有巧思。例如一般沙發太軟太矮，長輩往往一坐就陷下站不起來；在雙連的沙發骨架雖為市售柚木品牌，但自行開發的椅墊卻加厚了將近10公分，也加強了硬度，方便長輩行動。這種「適老性」的規畫是雙連的核心，串起每一個設備與服務。在雙連有將近一半的老人會使用電腦與上網，因此每間房間都有網路，還有一台功能經過整合簡化的ＳＣＤ（服務連接器），觸控一下螢幕就能打電話給家人。「不是有設備就夠了，還要訓練員工觀念與服務，以及所有家屬、長輩住民的參與，」蔡芳文說，銀髮產品不是憑空設想就行得通，一定要老人會用才算成功。他還特地在園區的交誼廳旁，規畫一個「雙連生活實驗室」（Living Lab）空間，開放給數十所國內外大專院校來雙連與老人互動與研習，老人也可和年輕學生一起開發各種適老化商品與服務。將雙連經營得有聲有色的靈魂人物，正是執行長蔡芳文。畢業於吳鳳工專電機系，早年在大同公司上班，因為信仰而加入旁邊的雙連教會，參與教會慈善服務，負責林森公園附近400多戶老榮民的社區拜訪與義診，20年前雙連教會教眾規畫辦理安養中心時，他便參與經營，後來還為此去念了台大醫管所。蔡芳文將商管概念應用於經營非營利組織上，也運用本身電機背景，與真茂等資通訊廠商開發商品，很早就把養老機構管理資訊化，把雙連經營得有聲有色，登門求教者絡繹不絕。據統計，去年就有720組海內外參訪團到雙連觀摩，來自中國的參訪團就有300團，儼然成為台灣安養中心第一品牌。「過去是可憐、同情，現在是要把養老做成產業，概念已完全不一樣了，」兩週前他才從安徽演講回來，當天早上又送走三團參訪外賓，現年63歲、一頭灰髮的他，講起雙連經驗仍活力十足。蔡芳文不藏私，樂於到處演講分享，而且講起策略、步驟、數字都條理分明。他指出，雙連醫療管理顧問服務已系統化為6階段：行業初期進入的會勘與評估市場定位、投資興建的內部細部規畫、開發各種適老化生活產品、人才培訓、營運所需的所有的ＳＯＰ（標準作業程式）和資訊表單，以及最後階段的陪伴營運，六階段管顧服務可依對方需求整套輸出或分拆提供。「很多機構都希望他們提供硬體，我們代管經營，但我認為幫他們訓練種子幹部，再由他們自己發展經營， 才是長久之計。」

醫療管理服務　六階段搞定 他坦言，雙連近年開始輸出養老管理顧問服務，與32家中國國企簽訂ＭＯＵ（合作備忘錄），啟動了九個合作案，最近在業界熱議的就是與上海斯米克控股結盟，發展中國大健康產業。「其實我是最近才認識李慈雄董事長，」蔡芳文指出，李慈雄雖然人在大陸，但父母、家人都在台灣，看到高齡化趨勢，很早就想踏入健康產業，去過日本、歐洲等很多機構參訪，有一天他慕名來到雙連，很受感動，經營團隊也分批來5、6次，才簽訂顧問合約。在台灣，雙連已協助3家安養機構複製雙連經驗，海外輸出管顧服務的客戶則以大陸國企為主，例如江蘇蘇州怡養護理院、浙江杭州通汝縣江南養生文化村、北京泰康保險養老之家北京燕園等，在中國業界非常受歡迎。 蔡芳文指出，整套服務雖然2到3年才會做完，但每年都可挹注營收數百萬元台幣，利潤高達7到8成。銀髮照護產業愈來愈有其急迫性，許多財團想切入卻往往不得其法，但蔡芳文卻抱持著只要來問就分享。「不能只有雙連好，要大家好、台灣才會好啊。最好要做到：講到養老就想到台灣，」把養老經營成社會企業的他，充滿熱忱地說。

国家卫计委 李斌: 健康中国 国家战略! 上市公司改名健康化!!

 "健康中国"有望升至国家战略 2015年10月22日继提出建设"美丽中国"之后，"健康中国"战略呼之欲出。十八届五中全会召开在即，关于"十三五"规划相关议题的讨论成为市场关注的焦点。上证报记者日前从权威渠道获悉，"健康中国"有望写入中央相关文件。而今年9月初，国家卫计委已全面启动《健康中国建设规划（2016-2020年）》编制工作。中国社会保障学会副会长申曙光昨日接受上证报记者采访表示，"将'健康中国'上升为国家战略有望全面推进医疗卫生体制改革。从资本市场角度看，在推进'健康中国'战略规划中，整个医疗卫生行业以及大健康产业将进入蓬勃发展期。就细分领域而言，医疗服务、健康保险、养老产业及互联网医疗等为首的上市公司有望率先受益。"

开启十万亿级健康盛宴 记者从卫计委了解到，"健康中国"建设规划是在"十三五"时期全面建成小康社会背景下，为满足人民群众不断增长的健康需求，打造健康中国，编制的一项全局性、综合性、战略性的中长期规划，也是"十三五"时期卫生计生事业发展的总体规划。国家卫计委主任李斌指出，该战略规划将从大健康、大卫生、大医学的高度出发，突出强调以人的健康为中心，实施"健康中国"战略并融入经济社会发展之中，通过综合性的政策举措，实现健康发展目标。"健康中国"战略已酝酿多年。早在2007年中国科协年会上，时任卫生部部长陈竺即公布了"健康护小康，小康看健康"的三步走战略。2012年8月，卫生部组织数百名专家讨论最终形成"健康中国2020"战略研究报告，提出到2020年，完善覆盖城乡居民的基本医疗卫生制度，实现人人享有基本医疗卫生服务，医疗保障水平不断提高，卫生服务利用明显改善，地区间人群健康差异进一步缩小，国民健康水平达到中等发达国家水平。值得关注的是，"健康中国"概念在今年全国两会期间再次亮相，并在今年9月进入战略编制工作，有望进一步上升至国家战略。李克强总理在两会政府工作报告中强调："健康是群众的基本需求，要不断提高医疗卫生水平，打造健康中国。"权威人士分析指出，下周将召开十八届五中全会，"十三五"规划将浮出水面，"健康中国"战略此时会否正式升级为国家战略备受期待与关注。对资本市场而言，一旦"健康中国"上升为国家战略，十万亿级产业投资盛宴将随之开启。相关研究报告显示，大健康产业已成为全球最大的新兴产业。然而与美国、日本甚至很多发展中国家相比，中国的大健康产业还处于起步阶段。统计数据显示，美国的健康产业占GDP比重超过15%，加拿大、日本等国健康产业占GDP比重超过10%。而我国的健康产业仅占GDP的4%-5%。"随着'健康中国'战略落地，'十三五'期间围绕大健康、大卫生和大医学的医疗健康产业有望突破十万亿市场规模。医疗健康产业也将引领新一轮经济发展浪潮。"上述分析人士指出。

上市公司抢先布局"健康中国"春江水暖鸭先知。在国家紧锣密鼓筹划"健康中国"战略之时，一些商业嗅觉敏锐的上市公司已经开始抢滩、加码健康产业。其中最受追捧的当属互联网医疗这一新兴产业。在今年国家大力推进"互联网+"行动计划的背景下，互联网医疗产业进入快速发展期。以海虹控股、九安医疗为首的互联网医疗公司纷纷加码主业并受到资本追捧，从互联网+医保到互联网+医疗，上述新型医疗服务公司有望借力移动互联网在健康中国中占据强势地位。国家卫计委主任李斌曾就医药产业"十三五"规划表示："希望打造'健康中国'，要更加注重医疗卫生工作重心下移和资源下沉。而互联网+医疗，改变的不仅是就医方式，更是推动医疗资源下沉、解决'排队3小时看病3分钟'等看病难问题的有效手段。"而记者此前调研了解到，未来互联网医疗正是可以降低交易成本、提高社会效率、增进人类福祉的革新，一直被"看病难、看病贵"痼疾所困扰的中国医疗健康领域亟须互联网这一工具来重塑。纵观A股公司近一年来的投资风向可见，大医疗、大健康已经深入上市公司之心。越来越多上市公司开始积极转型"从医"，甚至陆续有上市公司更名，新名称中加上"健康"字样。华邦健康、乐金健康等就是典型。今年9月，随着华邦颖泰完成定增发力皮肤类互联网医疗平台项目及医疗产业基地建设，公司加速推进"大华邦医疗联盟"战略，公司名称由"华邦颖泰股份有限公司"变更为"华邦生命健康股份有限公司"（简称华邦健康）。从事多年桑拿设备的公司桑乐金则坦言，鉴于公司目前"大健康"发展战略，原公司名称已不能全面准确地反映公司的业务内容与特点，故更名"乐金健康"，未来将立足健康产业，围绕家庭健康相关产品，成为健康环境、饮食、理疗、健身等品类的家庭健康系统服务商。

The era of iPS? Advances of reverses infertility induced by chemotherapy or Premature Ovarian Failure

Stem cell breakthrough reverss infertility after cancer Scientists from Egypt's Mansoura Medical School show it is possible to restore fertility by injecting stem cells directly into the ovaries   By Sarah Knapton, Science Editor12:01AM BST 22 Oct 2015Cancer patients made infertile by chemotherapy have been offered new hope after scientists succeeded in reversing the damage caused to eggs for the first time. In a landmark breakthrough hailed as "phenomenal" by fertility experts, researchers from Egypt and the US showed that injecting stem cells into ovaries can bring them back to life. Chemotherapy is toxic to the ovaries, destroying eggs and ovarian tissue and triggering early menopause in some women. Many younger women are now advised to freeze their eggs before undergoing cancer treatment, but in urgent cases there is often not time. Now scientists have shown it is possible to restore fertility by injecting stem cells directly into the ovaries. "This is very exciting piece of research that adds to our understanding of how cells differentiate to become egg stem cells." Although the procedure has only been carried out in mice so far, the results were so successful that the researchers say they are ready to move to human trials. Mice who had suffered ovarian failure from chemotherapy were able to have large litters after treatment. The new treatment offers hope to more than 20,000 women of childbearing age who are diagnosed with cancer each year, and could also help those suffering from early menopause and ovarian failure. Lead researcher Dr Sara Mohamed, of Mansoura Medical School in Egypt, said she had come up with the idea after meeting a 22-year-old cancer patient who was at risk of infertility from chemotherapy. "It was a very emotional for me so I decided to pursue it and work on it to figure it out," she said. "It a very common problem based on statistics of cancer female diagnosis every year. "We inject stem cells in the ovaries of mice which had chemotherapy and were damaged and we got very good ovarian function restoration in form of follicle number, hormonal production and finally getting pregnant and having new pups which was our ultimate goal. "We are now working on translating that into clinical trials (for humans). This approach carries high promise to women with chemotherapy-induced and potentially other types of premature ovarian failure." In the trial involving 18 mice, one group were given chemotherapy and then ovarian injections of bone marrow stem cells, while another group had ovarian injections of saline. A third, control, group, had saline injections without the preceding chemotherapy. Within a week researchers saw a boost in oestrogen, an essential hormone in ovulation, in the stem cell group followed by regeneration in ovarian tissue after a fortnight and an increase in the number of follicles. Follicles produce the hormones oestrogen and progesterone and each carry a single egg which they release at ovulation. The mice who had suffered ovarian failure were able to go on to have large litters of pups while those who had saline injections struggled. Consultant Gynaecologist Dr Stuart Lavery, of Imperial College, said: "This is very exciting piece of research that adds to our understanding of how cells differentiate to become egg stem cells. "Clearly, there remains an enormous amount of work to see whether these results would be transferable into humans. "But it does provide some realistic hope that post-chemotherapy patients who have been made menopausal could one day restore ovarian function and possibly fertility." The researchers are now hoping to move to human trials using umbilical cord or even embryonic stem cells although they will still have to convince regulators the procedures are safe. Recent trials to stimulate stem cells in the ovaries were banned by the Food and Drug Agency (FDA). Currently women diagnosed with cancer can be be offered egg freezing, or even early stage IVF, before chemotherapy. But many trusts have cut IVF funding and women are sometimes denied cryopreservation. The new therapy would give peace of mind for women that something could be done to reverse the damage caused by chemotherapy. And because the new technique regenerates ovarian tissue the new eggs could be even healthier than they were before chemotherapy, experts have suggested. Women are born with all their eggs but they degrade over time. Stem cells have the potential to make eggs brand new again. Dr Geoffrey Trew, consultant in Reproductive Medicine and Surgery at Hammersmith Hospital, London, said: "Fertility-wise, if this works it would be stupendous. "Certainly it does appear promising and anything you can do to regenerate and ovary is a good thing. "Theoretically if you are regenerating the ovary you should be getting better quality eggs. "Clearly we're not here yet, and it's good that the researchers are not over-claiming their findings, but it's a great proof of concept." Dr Edgar Mocanu, consultant gynaecologist at Rotunda Hospital in Dublin and board member of the International Federation of Fertility Societies, said: "This could open phenomenal opportunities for women. "Millions of women around the world undergo cancer treatment and some of them will become infertile through ovarian failure. "While cancer survival rates have increased dramatically, to date there is no effective method of preventing infertility after chemotherapy. It could also open new avenues for the treatment of menopause induced health issues." "This approach carries high promise to women with chemotherapy-induced and potentially other types of premature ovarian failure." Lead researcher Dr Sara Mohamed Dr Owen Davis president of the American Society for Reproductive Medicine: "If this experimental treatment can be translated to women who have lost ovarian function from chemotherapy, it will be a great advance. "Restoring ovarian hormone production, follicle development and fertility to chemotherapy patients is a potential new application for bone marrow donation that could help many women." Coventry-based fertility expert Richard Kennedy, president-elect of the International Federation of Fertility Societies, said: "One of the really important messages for our cancer colleagues is that when men or women present for treatment, think about their fertility, think about the impact of the cancer treatment on their fertility.

Thousands of cancer patients to be denied treatment "That is a really important message because the majority of people with cancer now are living for five years or longer, and many are surviving their cancers, so thought about the long-term impact of treatment is important." Katherine Taylor, of Ovarian Cancer Action, said: "This sounds very promising and we welcome any new research that helps us build on our knowledge of cancer and fertility. We look forward to seeing how this research advances in years to come." The research was presented at the annual sheeting of then American Society for Reproductive Medicine in Baltimore.

Autologous Stem Cells Transplantation in Patients With Idiopathic and Drug Induced Premature Ovarian Failure, ClinicalTrials.gov Identifier: NCT02043743, Sponsor:El-Rayadh Fertility Centre. Premature ovarian failure (POF), also known as premature ovarian insufficiency, primary ovarian insufficiency (this is the most accurate term as some women may still conceive), premature menopause, hypergonadotropic hypogonadism is defined as failure of the ovary to function adequately in a woman younger than 40 years, in its role either as an endocrine organ or as a reproductive organ, a condition characterized by amenorrhea, hypoestrogenism, and elevated serum gonadotropin levels (which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs) in women younger than 40 years. This condition occurs in approximately 1% of women and it has important physical and psychological consequences/impact in those patients. The purpose of this study is to investigate the role of the transplantation of bone marrow derived stem cells into ovarian tissue for treatment of premature ovarian failure and to assess their ability to differentiate into germ cells. This study is an open-label investigation of the efficacy of injection of autologous adult bone marrow derived stem cells into the ovarian stroma of patients with premature ovarian failure. Sixty women with premature ovarian failure will be recruited in this study after a written informed consent. Diagnosis will be based mainly on history taking, physical examination and investigations. Laboratory investigations will include Serum follicle-stimulating hormone (FSH), serum estrogen measurement and serum AMH. The anterior pituitary secretes FSH and LH at high levels due to the dysfunction of the ovaries and consequent low estrogen levels. Typical FSH in POF patients is over 40 mlU/ml (post-menopausal range). Subjects will be enrolled based on specific inclusion/exclusion criteria and evaluated at regular post transplant intervals. Human adult bone marrow derived stem cells will be transplanted by a gynecological surgeon through a standard surgical approach (transvaginal U/S guided approach). Subjects will be monitored frequently for a total of one year after adult bone marrow stem cells cell injection. For safety of participants, Bone Marrow Stem cells will be injected in one ovary only and the other ovary will be spared.

Ovarian cortex transplantation Time to move on from experimental studies to open clinical application, Posted by Thea Ryan on Wednesday, August 5, 2015 ,Authors:Jacques Donnez, M.D., Ph.D., Marie-Madeleine Dolmans, M.D., Ph.D., César Diaz, M.D., Ph.D., Antonio Pellicer, M.D., Ph.D.  Volume 104, Issue 5, Pages 1097-1098  Abstract: In the context of treating cancer, fertility preservation (FP) in young women is a major challenge. Many questions remain because controversial issues still exist (1). Unfortunately, only a small number of patients at risk of premature ovarian failure are referred to FP specialists to discuss different options. As reproduction specialists, we consider it vital to provide oncologists, hematologists, and all healthcare providers with accurate information, based on firm evidence, on fertility-sparing treatments, which could potentially have devastating consequences on their future quality of life.

Ovarian cortex transplantation in the baboon: comparison of four different intra-abdominal transplantation sites, Hum. Reprod. (2011) 26 (12): 3303-3311.BACKGROUND Several sites have been used for ovarian cortex transplantation (OCT) in humans. The present study was designed to evaluate different intra-abdominal transplantation sites in the baboon to gain further knowledge about alternative transplantation sites in a human setting.METHODS Autologous fresh OCTs were performed in 12 baboons (Papio anubis). Four different sites were tested: the free portion of the omentum (OMF), the portion of the omentum adjacent to the spleen (OMS), the pouch of Douglas (D) and the pelvic wall on the psoas muscle (PW). Cortex survival, follicle density, cyclicity and hormonal levels were compared between the different sites, 3 and 6 months after transplantation.RESULTS Macroscopically, antral follicles were only found in the OMS and OMF locations, which also showed a higher proportion of follicle-containing cortex at light microscopy (OMF 71.4%, OMS 83.3% versus PW 58.8% and D 40%, P< 0.05). Higher densities of primordial [OMF: 3.54 (0–13.18) follicles/grid, OMS: 3.85 (0–8.53), PW: 0 (0–13.25), D 0 (0–1.33), P< 0.05] and primary follicles [OMF: 3.54 (0–18.52), OMS: 3.85 (0–1), PW: 0 (0–4.58), D 0 (0–0.25), P< 0.05] was also found in the omental locations.CONCLUSIONS Omental locations provide a better site, in terms of follicle survival, for intra-abdominal OCT in the baboon compared with the pelvic wall and the D.