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PurposeTo evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy.MethodsCases were consecutive women with endometriosis managed in eleven Italian referral centers. Controls were women in whom endometriosis was excluded. All women filled in a questionnaire addressing previous natural pregnancies. Marginal logistic regression models were fitted to evaluate the impact of endometriosis on obstetric outcome. A post hoc analysis was performed within the endometriosis group comparing women with severe adenomyosis versus women with absent or mild adenomyosis.ResultsThree hundred and fifty-five pregnancies in endometriosis group and 741 pregnancies in control group were included. Women with endometriosis had a higher risk of preterm delivery < 34 weeks (6.4% vs 2.8%, OR 2.42, 95% CI 1.22–4.82), preterm delivery < 37 weeks (17.8% vs 9.7%, OR 1.98, 95% CI 1.23–3.19), and neonatal admission to Intensive Care Unit (14.1% vs 7.0%, OR 2.04, 95% CI 1.23–3.36). At post hoc analysis, women with endometriosis and severe adenomyosis had an increased risk of placenta previa (23.1% vs 1.8%, OR 16.68, 95% CI 3.49–79.71), cesarean delivery (84.6% vs 38.9%, OR 8.03, 95% CI 1.69–38.25) and preterm delivery < 34 weeks (23.1% vs 5.7%, OR 5.52, 95% CI 1.38–22.09).ConclusionWomen with endometriosis who conceive naturally have increased risk of preterm delivery and neonatal admission to intensive care unit. When severe adenomyosis is coexistent with endometriosis, women may be at increased risk of placenta previa and cesarean delivery.Trial registrationClinical trial registration number: NCT03354793.

Purpose To evaluate the role of post-surgical medical treatment with GnRHa in patients with DIE (Deep Infiltrating Endometriosis) that received complete or incomplete surgery laparoscopic excision. Methods Hundred fifty-nine patients with deep infiltrating endometriosis of the cul-de-sac and of the rectovaginal septum with pelvic pain undergoing laparoscopic surgery in academic tertiary-care medical center. Eighty patients underwent complete laparoscopic excision of DIE (Arm A) while 79 patients underwent incomplete surgery (Arm B). After surgery each surgical arm was randomized in two groups: no treatment groups 1A [40 pts] and 1B [40 pts] and GnRHa treatment for 6 months groups 2A [40 pts] and 2B [39 pts]. Pain recurrence and quality of life were evaluated in follow-up of 12 months and compared between groups. Results No differences were observed between patient groups 1A and 2A. Groups 1A, 2A and 2B obtained significantly lower pain scores than those achieved by the group 1B undergoing incomplete surgical treatment and no post-surgical therapy. At 1-year follow-up patients treated with en-block resection (Groups 1A and 2A) showed the lowest pain scores and the highest quality of life in comparison with the other two groups (Group 1B and 2B). Conclusion GnRHa administration is followed by a temporary improvement of pain in patients with incomplete surgical treatment. It seems that it has no role on post-surgical pain when the surgeon is able to completely excise DIE implants.

IntroductionCurrently, the adherence to nutritional guidelines is low, with alarming rates of obesity worldwide and micronutrient deficiencies documented even in industrialised countries. As a consequence, nutritional screening and counselling represent a critical subject in early pregnancy, aiming to improve pregnancy outcomes and population health.Methods and analysisIn this setting, the development of a simple and reproducible nutritional checklist is of utmost importance. The Simple Study is a longitudinal prospective multicentre study aiming to identify the associations between maternal nutritional habits in the first trimester, early markers of placental function and pregnancy outcomes on a large population of singleton pregnancies in Italy.Ongoing healthy singleton pregnancies will be enrolled at the ultrasound scan of the first trimester combined screening test (11+0–13+6 gestational weeks). A nutritional score measuring the adherence to a healthy diet and nutritional deficiencies will be collected at recruitment. Fetal (crown-rump length, nuchal translucency (NT), biparietal diameter, femur length) and utero placental (placental volume, uterine arteries Doppler velocimetry) ultrasound data and biochemical placental markers (pregnancy-associated plasma protein A, free ß-human chorionic gonadotropin) will be collected. Second and third trimester ultrasound records and birth outcomes will be recorded from medical registers. This study will set the stage for introducing a reproducible, time-saving and low-cost nutritional screening in pregnancy. The nutritional score will allow the implementation of specific corrective measures with potential large impact on placentation and pregnancy outcomes.Ethical and disseminationEthical approval for this study was obtained from the Milano Area 1 Ethics Committee (No 46091, 7 November 2018) prior to the commencement of the research.The dissemination plan includes the presentation of abstracts and findings at national and international scientific meetings.

Introduction/BackgroundTo describe the accuracy and detection rate of sentinel lymph node (SLN) identified by dual cervical indocyanine green (ICG) injection, underlining the incidence of Isolated Tumor Cells (ITC) following SLN ultrastaging.MethodologyBetween December 2015 and May 2019, 40 women with early stage Endometrial Cancer (EC) were scheduled for total laparoscopic or laparotomic hysterectomy, bilateral oophorectomy and SLN detection.ResultsA total of 40 procedures was performed. The patient mean age was 65 years (SD 12.2) and mean body mass index was 26 kg/m2 (SD 6.9). Histological types were endometrioid adenocarcinoma in 29 cases (73%), 7 endometrial hyperplasia (19%), 3 serous adenocarcinoma (5%), 1 mixed histology (3%).The detection rates were as follow: 97% (39/40) overall for SLNs; unilateral and bilateral mapping of SLNs were achieved in 20% and 72% of subjects respectively (undetermined laterality in 2 cases and unobserved SLN in 1 case). The main lymphatic stations were external iliac (57%) and interiliac (45%). Positive SLNs were 8, identified in 7 out of 40 patients (17%), including 4 patients with ITC (57% - 4/7) (2 in the EI area, 1 in the II area, 1 in the interiliac area). The oncological risk of ITC positive patients was in 1 low, 2 intermediate and 1 high/intermediate risk cases. All patients with ITC were discussed by a multidisciplinary team and none of them received adjuvant therapy. Five months after surgery, 1 patient presented inguinal node and vaginal cuff relapse. She underwent EBRT& BRT with a complete response. At this moment all these patients are free of disease.ConclusionSLN ultrastaging increases the number of nodes considered positive, especially the identification of ITC. In our population the overall incidence of ITC was 10% and in those who had positive SLN, ITC were detected in 57%. We observed in these patients an excellent prognosis.DisclosureNothing to disclose.

Introduction/BackgroundBRCA 1 and 2 mutated women have a 40–85% lifetime risk of developing breast cancer (BC) and 16–64% risk of ovarian cancer (OC). Literature data evaluating the role of pregnancies on risk of BC and OC in BRCA mutated patients are controversial. The objective of the present study is to evaluate the impact of pregnancy on cancer risk in a cohort of BRCA1/2 mutated patients.MethodologyThis is a retrospective study, conducted on a sample of 106 female patients, 83 (78%) with BRCA 1 mutation and 23 (22%) BRCA 2, involved in a follow-up program of two different divisions of the University of Cagliari. We evaluated the number of BC and OC and the age of cancer diagnosis correlating to the number of pregnancies.ResultsOf 106 patients, 39 (36,8%) patients did´t have diagnosis of cancer and 67 (63,2%) developed cancer: 48 BC, 12 OC and 7 both. Thirthy-nine (36,8%) women didn´t have pregnancy, 21 (19,8%) had one pregnancy, 27 (25,4%) had two pregnancies and 19 (17,9%) more than two pregnancies.The median age at the cancer diagnosis was 43,3 years (range 19–69 years).We found a significative difference on the age of cancer diagnosis in patients with two or more pregnancies (p-value <0,001). Patients with no or one pregnancy developed cancer at a median age of 38,3 years (range 19–59 ys), patients with two or more pregnancies at 49,5 ys (29–69 ys).ConclusionOur results seems to suggest a protective effect of pregnancy on the development of cancer in BRCA mutated women. Data show that two or more pregnancies significantly delay the development breast and ovarian cancer.DisclosureNothing to disclose.

The objective of this work was to image the presence of impact damage by monitoring the nonlinear response of damaged carbon/epoxy composite samples. The presence of microcracks, debonding, delamination, etc… induce the material to behave in a nonlinear elastic fashion highlighted by the presence and amplitude of harmonics in the spectrum of the received signal when the sample is periodically excited at one of its resonance frequencies. The sensitivity of a second harmonic imaging technique (SEHIT) based on material nonlinear elastic effect known as second harmonic generation (SHG) was investigated. The proposed imaging process was used to detect barely visible impact damage (BVID) due to low velocity impact (<12 J). The results showed that the SEHIT methods appear to be highly accurate in assessing the presence and magnitude of damage with a very promising future for both NDT and possibly structural health monitoring (SHM) applications. Moreover the technique was validated with two conventional NDT techniques: pulse thermography and thermosonics. The first NDT method failed in detecting the damage on the impacted face. The second technique was capable of localising and quantifying the damage on the impacted surface agreeing well with the results obtained using the proposed nonlinear imaging method.

Abstract A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen–progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate–severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen–progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen–progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

Plenty of authors propose outpatient hysteroscopy as the gold standard diagnostic method for the evaluation of endometrial pathology. This statement has been strengthened in the recent years due to the wide use of smaller diameter hysteroscopic devices, which have made the dilation of the cervix and the use of anesthesia unnecessary. The main purpose of this paper is to summarize the indications of diagnostic hysteroscopy. In this review, we used the most recent publications in MEDLINE and Cochrane Library in order to specify the indications of diagnostic hysteroscopy and the experience that have been obtained till today in the management of certain pathological uterine conditions. The key words we used were diagnostic hysteroscopy, abnormal uterine bleeding, infertility, endometrial cancer. Hysteroscopy provides an accurate method of evaluation and direct visualization of the endometrial cavity and moreover directed biopsy and sampling of suspected lesions. Last years with the continuous development in the hysteroscopy devices, plenty of women benefit surgical hysteroscopy techniques for uterine abnormalities. Hysteroscopy is useful for the diagnosis in patients with abnormal uterine bleeding, with endometrial cancer and in infertile women. Hysteroscopy has the unique advantage of combining a thorough procedure with great diagnostic accuracy. The only disadvantage is that hysteroscopy requires specific teaching and training and has a long learning curve.

Purpose To evaluate whether laparoscopic treatment with a diode laser is feasible, safe, and effective in symptomatic patients affected by deep endometriosis (DE). Methods This retrospective study was performed using medical record data. The surgical reports, chronic pain scores, and quality of life (QoL) data were evaluated for 50 patients who had undergone laparoscopic surgery between November 2017 and March 2019 at two university hospitals (Monserrato (CA) and Foggia, Italy). Indications for surgery were chronic pelvic pain and/or infertility in patients who wished to conceive spontaneously. Endometriosis lesions/nodules were excised using a diode laser (Leonardo®, Biolitec® DUAL 45) that can combine 980 and 1470 nm wavelengths transmitted through a 1000 µm conical optical fibre. Results The median patient age was 32 years (range 21–44), with a body mass index (BMI) mean of 21.7  ±  2.9 kg/m 2 . The mean operation time was 147 min (range 106–190). No intraoperative or early complications (< 30 days) were reported. All patients left the hospital, on average, within 3 days (range 2–9 days) after surgery. A significant improvement in pain was observed at the 3-, 6-, and 12-month follow-up ( p  < 0.01) in all patients. Moreover, patients reported a significant QoL improvement at the 12-month follow-up. Conclusion The diode laser confirmed its feasibility and safety for treating endometriosis. During the shaving surgical procedure, the diode laser system ensures a safe and effective laparoscopic dissection of deep endometriotic lesions. Further comprehensive randomized trials are necessary to confirm these preliminary data in terms of efficacy, recurrence rates, and pregnancy outcomes.

The aim of the present study was to evaluate the effectiveness of the ultramicronized-palmitoylethanolamide (um-PEA) and co-micronised palmitoylethanolamide/polydatin m(PEA/PLD) in the management of chronic pelvic pain related to endometriosis in patients desiring pregnancy. Thirty symptomatic women with laparoscopic diagnosis of endometriosis and pregnancy desire were enrolled. Patients were treated with um-PEA twice daily for 10 days followed by m(PEA/PLD) twice daily for 80 days. Intensity of chronic pelvic pain, dyspareunia, dysmenorrhea, dyschezia, and dysuria were evaluated at baseline, after 10, 30, 60, 90 days and after 30 days from the end of treatment, by VAS. Quality of life and women's psychological well-being were evaluated at baseline and at the end of the treatment after 90 days with 36-Item Short Form Health Survey questionnaire and Symptom Check list-90 questionnaire, respectively. All collected data were analyzed with the non-parametric Wilcoxon test. At the end of the treatment, all patients showed a significant improvement in chronic pelvic pain, deep dyspareunia, dysmenorrhea, dyschezia, as well as in quality of life and psychological well-being. In spite of the study's limited sample size and the open-label design, this research suggests the efficacy of um-PEA and m(PEA/PLD) in reducing painful symptomatology and improving quality of life as well as psychological well-being in patients suffering from endometriosis. Additionally, this treatment did not show any serious side effect, proving particularly suitable for women with pregnancy desire and without other infertility factors.