Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Genetica, clinica e diagnostica strumentale degli ipopituitarismi congeniti

L’ipopituitarismo è una sindrome endocrina caratterizzata dalla ridotta o assente secrezione di uno o più ormoni adenoipofisari, con conseguente disfunzione delle ghiandole periferiche corrispondenti. Il deficit di tutti gli ormoni configura il quadro di pan-ipopituitarismo, la carenza di due o più ormoni è detta ipopituitarismo parziale, mentre il deficit di un solo ormone viene definito ipopituitarismo selettivo. Il pan-ipopituitarismo è una condizione rara, invece l’ipopituitarismo parziale, soprattutto quello iatrogeno, è più frequente. Esistono varie forme congenite ed acquisite, organiche e funzionali. L'ipopituitarismo congenito è causato da mutazioni di diversi geni che codificano per i fattori di trascrizione. Il fenotipo varia a seconda del fattore di trascrizione coinvolto: PROP1 (deficit degli ormoni somatolattotropo, tireotropo, gonadotropo e a volte corticotropo) (fig. 1), POU1F1 (carenza degli ormoni somatolattotropo e tireotropo, ipoplasia ipofisaria) (fig. 2), HESX1 (carenze ipofisarie variabili, displasia setto-ottica) (fig. 3) , e meno frequentemente LHX3 (deficit degli ormoni somatolattotropo e gonadotropo, limitazioni nella rotazione del capo e del collo) (fig. 4) e LHX4 (deficit ipofisari variabili, ectopia della neuroipofisi, anomalie dell'encefalo). Il quadro clinico dipende dall’ormone carente, dal grado di insufficienza della ghiandola e dall’età di insorgenza. Nell’età evolutiva prevalgono le forme idiopatiche-congenite, che si manifestano essenzialmente con ritardo della crescita e della pubertà ed assenza dell’adrenarca; il deficit di TSH induce quadri clinici diversi in base all’età in cui si presenta. Nell’età adulta prevalgono le forma acquisite, tra cui il macroedema ipofisario, che distrugge gradualmente l’ipofisi compromettendo nell’ordine la secrezione di GH, poi quella delle gonadotropine, TSH ed infine ACTH

Current Insights Into Inositol Isoforms, Mediterranean and Ketogenic Diets for Polycystic Ovary Syndrome: From Bench to Bedside.

Background: Polycystic ovary syndrome (PCOS) is a complex syndrome characterized by reproductive and metabolic implications. Lifestyle changes, such as diet and exercise, are considered first-line treatment for women affected by PCOS. Pharmacologic treatments target the hormonal and metabolic dysregulations associated to the disease such as insulin resistance, anovulation, hirsutism and menstrual irregularities. Objective: To focus on the role of inositol isoforms, as well as Mediterranean and ketogenic diets, as possible therapeutic strategies in PCOS women. Method: Narrative overview, synthesizing the findings of literature retrieved from searches of computerized databases. Results: Accumulating evidence suggests that two inositol isoforms, myo- and D-chiro-, may play a pivotal role in re-addressing both hormonal and metabolic parameters toward homeostasis, counteracting the symptoms and signs typical of this syndrome. In addition, studies focused on Mediterranean and ketogenic diet provided positive results in patients affected by obesity and type 2 diabetes, so these dietetic regimens could represent a fascinating dietetic treatment for the management of PCOS. Conclusion: Both the isoforms of inositol are effective in improving ovarian function and metabolism in patients with PCOS. In spite of accumulating evidence, it is currently not possible to draw firm conclusion(s) about the efficacy of these interventions considering the severe bias due to different samples size, dose, and duration of intervention among the published studies on this topic. Furthermore, future longitudinal cohort studies along with prospective interventional trials may contribute to better clarify the role of Mediterranean and ketogenic diets in the treatment of PCOS

Sindrome di Mayer- Rokitansky: Aspetti genetici, clinici, radiologici e prospettiveterapeutiche

La sindrome di Mayer-Rokitansky-Kuster-Hauser (MRKH) è una rara anomalia congenita dell'apparato genitale femminile che consiste nell'agenesia dell'utero e della vagina, ha una incidenza stimata di 1:4500, ed in genere si presenta con carattere sporadico. Le ovaie e tube di fallopio morfologicamente normali, cosi come lo sviluppo dei caratteri sessuali secondari ed il cariotipo. Un’interazione di fattori genetici ed ambientali è l’ipotesi eziopatogenetica più plausibile. La trasmissione sembra essere autosomica dominante con penetranza incompleta ed espressività variabile. Sono stati individuati diversi geni tra cui TCF2 e LHX1. La RMN è particolarmente adatta per la sua multiplanarietà e l’attitudine allo studio dei tessuti molli ed è più specifica ed accurata nella valutazione dell’aplasia uterina rispetto all’ecografia. Il trattamento delle pazienti con sindrome MRKH prevede la ricostruzione del canale vaginale che, in casi selezionati, si può eseguire anche con metodiche non invasive “Franck's dilator method”, tecnica Williams e Mc Indoe. Tra le prospettive terapeutiche anche il trapianto di mucosa vaginale umana autologa “in vitro”, mediante vaginoplastica

Preliminary results of a single-arm pilot study to assess the safety and efficacy of visnadine, prenylflavonoids and bovine colostrum in postmenopausal sexually active women affected by vulvovaginal atrophy

This single-arm pilot study enrolled 47 post-menopausal women affected by vulvovaginal atrophy (VVA). The Vaginal Health Index Score (VHIS) was evaluated for all women and all completed the Female Sexual Function Index (FSFI) questionnaire at baseline (T0) and after 15 days of vaginal cream treatment with one application per day (T1). Following treatment there was a significant improvement in all VHIS parameters and total score (p < 0.0001). Similarly, there was a significant improvement on four FSFI domains (lubrication, orgasm, satisfaction and pain) and total score (p = 0.001). None of the patients reported any local or systemic side-effects during treatment. © 2017 Elsevier B.V

Supplementary Material for: Hashimoto’s thyroiditis negatively influences ICSI outcome in euthyroid women on T4 substitution therapy; a retrospective study

Abstract Objective: To analyze the impact of thyroid autoimmunity (TAI) on reproductive outcome parameters of ICSI cycles as compared to TAI negative ICSI cycles. Design: In this single IVF center retrospective study 86 infertile women with elevated TPOAb or TGAb levels, but euthyroid after thyroxine replacement (study group), were compared to 69 female patients with no thyroid abnormalities (controls). Following ICSI treatment fertilization rate (FR), clinical pregnancy rate (CPR), miscarriage rate (MR) and live birth rate (LBR) were analyzed. Materials, Setting, Methods: All subjects with various infertility factors were treated with ICSI in university based IVF center. Patients in the study group received thryroxine replacement and were euthyreoid at IVF treatment. Before the IVF cycles endocrinological parameters were uniformly assessed: thyroid function and antibodies, reproductive hormones (AMH, FSH, LH, E2, PRL, testosterone, DHEAS, 17-OHP, AD) and OGTT (0-60-120 min glucose and insulin). Following descriptive comparison of laboratory parameters, age adjusted analyses of FR, CPR, MR and LBR were performed. Results: TAI positive women were older (mean age 35.31±4.95 vs. 32.15±4.87 years; p=0.002), had higher FSH (8.4±3.4 vs. 7.4±2.32 U/L; p=0.024), higher E2 (53.94±47.61 vs. 42.93±18.92 pg/ml; p=0.025) levels, while AMH (2.88±2.62 vs. 3.61±1.69 ng/ml; p=0.0002) was lower. There were no differences in TSH levels (1.64±0.96 vs. 1.66±0.65 uIU/ml; p=0.652) between the two groups. FT3 (2.63±0.58 vs. 2.98±0.55 pg/ml; p=0.002) was lower and FT4 (1.3±0.29 vs. 1.13±0.21 ng/dl; p=0.0002) was higher in the TAI positive group, reflecting clinically irrevelant differences. Egg cell counts (6±3.8 vs. 7.5±3.95; p=0.015) were lower in TAI and remained so following age adjustment. Although the overall ICSI FR did not differ (62.9 % vs. 69.1 %, p=0.12), it was lower for patients under 35 with TAI showing decreasing differences in line with age. The CPR (36.04 % vs. 69.56 %; p<0.001), LBR (23.25 % vs. 60.86 %; p<0.001) were lower, the MR (35.48 % vs. 12.5 %; p=0.024) was higher in the TAI group and these differences remained after age adjustment. Limitations: Since the higher age of the study group may interfere with the effect of TAI, age adjustment calculations were necessary to perform to eliminate this confounding factor. Conclusion: Despite optimal thyroid supplementation in clinical or subclinical hypothyreoidism, the presence of TAI negatively influences clinical pregnancy rate and is connected to a higher miscarriage rate, thus resulting in a lower live birth rate after ICSI. Decreased fertilization rate with ICSI in TAI patients may also contribute to poorer outcomes, especially in younger women

Supplementary Material for: Transvaginal Sonography for the preoperative assessment of parametrial deep infiltrating endometriosis: a diagnostic accuracy study

Objective: To evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria. Design: Diagnostic accuracy study based on a prospective observational design Participants: All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. Setting: Endometriosis referral hospital Methods: We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE of TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard. Results: In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p=0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70%-96.92%, 95% CI) for the right side and 87.91% (79.40%-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90%-98.84%, 95%CI) and 96.22% (94.04%-97.74%, 95% CI), respectively. Limitations: The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives. Conclusions: TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice

When one size does not fit all: Reconsidering PCOS etiology, diagnosis, clinical subgroups, and subgroup-specific treatments

Polycystic Ovary Syndrome (PCOS) is a complex endocrine disorder that affects a large proportion of women. Due to its heterogeneity, the best diagnostic strategy has been a matter of contention. Since 1990 scientific societies in the field of human reproduction have tried to define the pivotal criteria for the diagnosis of PCOS. The consensus Rotterdam diagnostic criteria included the presence of hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology (PCOM), and have now been updated to evidence based diagnostic criteria in the 2018 and 2023 International Guideline diagnostic criteria endorsed by 39 societies internationally. Within the Rotterdam Criteria, at least two out of three of the above-mentioned features are required to be present to diagnose PCOS, resulting in four phenotypes being identified: phenotype A, characterized by the presence of all the features, phenotype B, exhibiting hyperandrogenism and oligo-anovulation, phenotype C, presenting as hyperandrogenism and PCOM and finally the phenotype D that is characterized by oligo-anovulation and PCOM, lacking the hyperandrogenic component. However, it is the hypothesis of the EGOI group that the Rotterdam phenotypes A, B, and C have a different underlying causality to phenotype D. Recent studies have highlighted the strong correlation between insulin resistance and hyperandrogenism, and the pivotal role of these factors in driving ovarian alterations, such as oligo-anovulation and follicular functional cyst formation. This new understanding of PCOS pathogenesis has led the authors to hypothesis that phenotypes A, B, and C are endocrine-metabolic syndromes with a metabolic clinical onset. Conversely, the absence of hyperandrogenism and metabolic disturbances in phenotype D suggests a different origin of this condition, and point towards novel pathophysiological mechanisms; however, these are still not fully understood. Further questions have been raised regarding the suitability of the “phenotypes” described by the Rotterdam Criteria by the publication by recent GWAS studies, which demonstrated that these phenotypes should be considered clinical subtypes as they are not reflected in the genetic picture. Hence, by capturing the heterogeneity of this complex disorder, current diagnostic criteria may benefit from a reassessment and the evaluation of additional parameters such as insulin resistance and endometrial thickness, with the purpose of not only improving their diagnostic accuracy but also of assigning an appropriate and personalized treatment. In this framework, the present overview aims to analyze the diagnostic criteria currently recognized by the scientific community and assess the suitability of their application in clinical practice in light of the newly emerging evidence