Prevention Strategy of Intrauterine Adhesions: update and future perspective

Intrauterine adhesions (IUAs) caused by endometrial injury have a serious impact on women's fertility and morbility and involves a wide range of patients. Although the first case of IUAs was published in 1984 by Heinrich Fritsch, a full description of Asherman syndrome was done by Joseph Asherman. IUAs lead to a lot of complications in women, as the partial or complete closure of the uterine cavity, which may result in symptoms including abnormal menstruation, pelvic pain, recurrent pregnancy loss, secondary infertility, and pregnancy complications. Hysteroscopy, which has relegated blind curettage, is currently considered the gold standard diagnostic and therapeutic approach also as for outpatients. However, an integrated approach, including preoperative, intraoperative and postoperative procedures is needed to improve the reproductive outcome of the complex syndrome. In the post-operative care, the patient can benefit from some therapeutic and prophylactic methods used alone or in combination with each other. In this review, authors discuss on the efficacy of traditional methods for the prevention of complications of IUAs after surgery, such as hormonal therapy, physical barriers, vasodilators and antibiotics, as well as novel strategies such as stem cell therapy and novel therapeutic agents

A Case of Retroperitoneal Fibroid and Literature Review

Uterine fibroids or leiomyomas are the most common benign female genital tumors, although this pathology can also manifest itself outside the uterus, as in the case we present, with a retroperitoneal development. In this article, authors showed a rare case of 81-year-old women, with a right pelvic mass and lower abdominal discomfort. Basing on a preoperative radiological imaging, clinicians oriented to a provisional diagnosis of mesenchymal neoplasm of an uncertain origin. During surgery in the retroperitoneal space, it was detected a huge mass close to the uterus, beneath the right broad ligament. After the opening of the retroperitoneal spaces, surgeons enucleated a well-demarcated tumor, measuring 12 x 7 cm in diameter and histopathological findings demonstrated a rare retroperitoneal uterine leiomyoma

Hemorrhagic corpus luteum: Clinical management update

Hemorrhagic corpus luteum (HCL) is an ovarian cyst formed after ovulation and caused by spontaneous bleeding into a corpus luteum (CL) cyst. When HCL rupture happens, a hemoperitoneum results. Clinical symptoms are mainly due to peritoneal irritation by the blood effusion. The differential diagnosis is extensive and standard management is not defined. The authors elaborated a comparison of the differential diagnosis and therapeutic modalities from the laparoscopic approach to nonsurgical, medical options because hemorrhage from HCL is often self-limiting. The authors reviewed all data implicated with the development of HCL, trying to give homogeneity to literature data. The authors analyzed extensive literature data and subdivided the medical approach into many topics. The wait-and-see attitude avoids unnecessary laparoscopic surgery using supportive therapies (antifibrinolytic, analgesics, liquid infusion, transfusions and antibiotic prophylaxis). Surgical therapy: operative management should be laparoscopic, with surgical options such as luteumectomy, ovarian wedge-shaped excision or oophorectomy. Prevention: the possibility to preserve fertility is essential, mainly in patients with bleeding disorders or undergoing anticoagulant therapy; therefore, they need estro-progestinics or GnRH analogues to prevent ovulation and avoid further episodes of HCL. This review will aid physicians in making an early diagnosis of HCL, to avoid unnecessary surgery, and use the most effective treatment

Endoscopic surgical procedures for cervical cancer treatment: a literature review

Cervical cancer remains the leading cause of death by gynecologic cancer worldwide, comprising 15% of all cancers in women younger than 40 years. Standard treatments of invasive cancer in early stages are radical hysterectomy and pelvic radiotherapy, both of which are almost reliable by minimal invasive surgery, so as traditional laparoscopy and robotic-assisted surgery. Moreover, 45% of reproductive-age women are diagnosed with stage IB1 disease, making the fertility-sparing procedure, radical trachelectomy, a viable option for most patients for treatment of early-stage cervical cancer and maintenance of future fertility. This chapter focuses on emerging surgical techniques, including the laparoscopic and robotic approach, are improving perioperative outcomes for these patients. A manual and computer-aided search was carried out for all reviews related to this topic, randomized controlled trials, prospective observational studies, retrospective studies and case reports published between 1980 and 2012, assessing robotic surgery, Search strings were: laparoscopic surgery; robot or robot-assisted surgery; radical hysterectomy; cervical cancer, minimally invasive surgery. Robotic-assisted gynecologic surgery has increased worldwide, considering the number of scientific articles dedicated to it though few retrospective and prospective studies have demonstrated the feasibility of robotic-assisted surgery in radical hysterectomy. In general, robot-assisted gynecologic surgery is often associated with longer operating room time but generally similar clinical outcomes, decreased blood loss, and shorter hospital stay. Robotic-assisted procedures are not, however, without their limitations: the equipment is still very large, bulky, and expensive, the staff must be trained, specifically on draping and docking the apparatus to maintain efficient operative times. Functional limitations include lack of haptic feedback, limited vaginal access, limited instrumentation, and larger port incisions. Exchanging instruments becomes more cumbersome and requires a surgical assistant to change the instruments. Additionally, the current robotic instruments do not include endoscopic staplers or vessel sealing devices. Finally, laparoscopic radical hysterectomy is a feasible and safe procedure that is associated with fewer intraoperative and postoperative complications than abdominal radical hysterectomy. The role of robotic-assisted surgery is continuing to expand, but well-designed, prospective studies with well-defined clinical, long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life, are needed to fully assess the value of this new technology in radical hysterectomy. Scientific literature has shown the feasibility of a radical resection by minimally invasive oncological surgery and documented an equivalent number of pelvic nodes harvested by laparoscopy and open surgery. Women with a tumor size 2 cm or smaller and stage IA1 with lymphovascular space involvement (LVSI), IA2, or IB1 disease may be offered fertility-sparing treatment after thorough evaluation by an oncologist trained in this management

High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis.

BACKGROUND: Early diagnosis of acute myocardial infarction (AMI) can ensure quick and effective treatment but only 20% of adults with emergency admissions for chest pain have an AMI. High-sensitivity cardiac troponin (hs-cTn) assays may allow rapid rule-out of AMI and avoidance of unnecessary hospital admissions and anxiety. OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of hs-cTn assays for the early (within 4 hours of presentation) rule-out of AMI in adults with acute chest pain. METHODS: Sixteen databases, including MEDLINE and EMBASE, research registers and conference proceedings, were searched to October 2013. Study quality was assessed using QUADAS-2. The bivariate model was used to estimate summary sensitivity and specificity for meta-analyses involving four or more studies, otherwise random-effects logistic regression was used. The health-economic analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different troponin (Tn) testing methods. The de novo model consisted of a decision tree and Markov model. A lifetime time horizon (60 years) was used. RESULTS: Eighteen studies were included in the clinical effectiveness review. The optimum strategy, based on the Roche assay, used a limit of blank (LoB) threshold in a presentation sample to rule out AMI [negative likelihood ratio (LR-) 0.10, 95% confidence interval (CI) 0.05 to 0.18]. Patients testing positive could then have a further test at 2 hours; a result above the 99th centile on either sample and a delta (Δ) of ≥ 20% has some potential for ruling in an AMI [positive likelihood ratio (LR+) 8.42, 95% CI 6.11 to 11.60], whereas a result below the 99th centile on both samples and a Δ of < 20% can be used to rule out an AMI (LR- 0.04, 95% CI 0.02 to 0.10). The optimum strategy, based on the Abbott assay, used a limit of detection (LoD) threshold in a presentation sample to rule out AMI (LR- 0.01, 95% CI 0.00 to 0.08). Patients testing positive could then have a further test at 3 hours; a result above the 99th centile on this sample has some potential for ruling in an AMI (LR+ 10.16, 95% CI 8.38 to 12.31), whereas a result below the 99th centile can be used to rule out an AMI (LR- 0.02, 95% CI 0.01 to 0.05). In the base-case analysis, standard Tn testing was both most effective and most costly. Strategies considered cost-effective depending upon incremental cost-effectiveness ratio thresholds were Abbott 99th centile (thresholds of < £6597), Beckman 99th centile (thresholds between £6597 and £30,042), Abbott optimal strategy (LoD threshold at presentation, followed by 99th centile threshold at 3 hours) (thresholds between £30,042 and £103,194) and the standard Tn test (thresholds over £103,194). The Roche 99th centile and the Roche optimal strategy [LoB threshold at presentation followed by 99th centile threshold and/or Δ20% (compared with presentation test) at 1-3 hours] were extendedly dominated in this analysis. CONCLUSIONS: There is some evidence to suggest that hs-CTn testing may provide an effective and cost-effective approach to early rule-out of AMI. Further research is needed to clarify optimal diagnostic thresholds and testing strategies. STUDY REGISTRATION: This study is registered as PROSPERO CRD42013005939. FUNDING: The National Institute for Health Research Health Technology Assessment programme

Can trans resveratrol plus d-chiro-inositol and myo-inositol improve maternal metabolic profile in overweight pregnant patients?

Objective. To investigate the effect of trans-resveratrol from Polygonum cuspidatum/magnesium hydroxide complex, trademark Revifast®, plus D-chiro-inositol (DCI) and Myo-inositol (MI) during spontaneous pregnancies in overweight patients in a pilot study. Study design. A one-year, prospective, randomized, doubleblinded, placebo-controlled single center clinical study was carried out on overweight pregnant women. 110 patients were randomized in 3 groups to receive: Revifast® with DCI/MI (group I), DCI/MI alone (group II) or control group (group III) for 30 and 60 days. The main outcomes were to explore the lipid profile (total cholesterol, LDL, HDL, TG) and glucose levels, after 30 and 60 days of therapy. Results. No difference in systolic and diastolic parameters among 3 groups during study. All blood chemistry parameters improved compared to placebo at 30 days already, but significantly to 60 days, respect placebo. By comparing the two treatment groups, group I demonstrates significantly improved lipid and glucose parameters than group II, which are at 30 to 60 days of treatment. Conclusion. The supplementation of Trans-resveratrol, Revifast® in addition to DCI/MI in overweight pregnant woman with an elevated fasting glucose improves glucose levels, Total Cholesterol, LDL and TG

Intrapartum ultrasound during prolonged second stage of labor: a diagnostic tool suggested for operative delivery to reduce complications.

Diagnosis and management of prolonged second stage of labor and its complications is difficult and often poses a dilemma to the treating obstetrician regarding timing and type of intervention. Nowadays, the diagnosis of dys-tocic prolonged second stage of labor is largely based on digital evaluation of cervical dilatation and fetal head station and position, resulting inaccurate and subjective. Moreover, the problem of timing of delivery for nullipa-ra during dystocic labor and labor analgesia is clinically unsolved, as well as questioned since many years. Thus, labor management is largely based upon clinical and not instrumental findings. Women in dystocic labor require, often, operative delivery, after many hours of pain during labor. Accurate assessment of fetal head position and station is crucial in clinical decision-making during the second stage of labor and the fetal station was misinter-preted as lower than it really was in 15–22% of cases. Misdiagnosis or failure to correctly identify the fetal head position and station is one of the causes of failed instrumental delivery and subsequently of higher rate of neona-tal morbidity. Intrapartum ultrasound also distinguishes patients destined for spontaneous vaginal delivery from those to submit to operative delivery. The intrapartum US is an adjunctive tool for labor ward obstetricians in the management of prolonged second stage and dystocia. It is a more objective and reliable tool than digital ex-amination, and may give the obstetrician a more accurate perspective before making crucial clinical decisions re-garding the chances of a successful vaginal delivery, and may lower the rate of failed instrumental delivery and its associated morbidity

Abdominal Infrarenal Aortic Stenosis Approached Through a Full Transradial Approach: A Case Series

Six consecutive patients (3 men; mean age, 63 +/- 14 years; age range, 38-81 years) with infrarenal abdominal aortic stenosis underwent unilateral or bilateral transradial approach for stenting of the aortic lesion. In 4 cases, isolated aortic stenting was performed through single transradial approach (in 2 cases with precise alignment to the proximal end of previously deployed iliac stents), whereas in the other 2 cases bilateral transradial approach was used for aortic stenting followed by bilateral stenting of the proximal iliac arteries. Either a "bare-on-the-wire" or a " support-catheter" technique was used, according to patient anatomy and technical requirements. The median follow-up was 14.3 months, at which time all patients had relief of symptoms without thromboembolic or bleeding complications. In this performance and safety evaluation, full transradial approach was effective and safe for treating infrarenal aortic stenosis that is isolated or associated with iliac disease

Can trans resveratrol plus d-chiro-inositol and myo-inositol improve maternal metabolic profile in overweight pregnant patients?

Objective. To investigate the effect of trans-resveratrol from Polygonum cuspidatum/magnesium hydroxide complex, trademark Revifast®, plus D-chiro-inositol (DCI) and Myo-inositol (MI) during spontaneous pregnancies in overweight patients in a pilot study. Study design. A one-year, prospective, randomized, doubleblinded, placebo-controlled single center clinical study was carried out on overweight pregnant women. 110 patients were randomized in 3 groups to receive: Revifast® with DCI/MI (group I), DCI/MI alone (group II) or control group (group III) for 30 and 60 days. The main outcomes were to explore the lipid profile (total cholesterol, LDL, HDL, TG) and glucose levels, after 30 and 60 days of therapy. Results. No difference in systolic and diastolic parameters among 3 groups during study. All blood chemistry parameters improved compared to placebo at 30 days already, but significantly to 60 days, respect placebo. By comparing the two treatment groups, group I demonstrates significantly improved lipid and glucose parameters than group II, which are at 30 to 60 days of treatment. Conclusion. The supplementation of Trans-resveratrol, Revifast® in addition to DCI/MI in overweight pregnant woman with an elevated fasting glucose improves glucose levels, Total Cholesterol, LDL and TG. © Società Editrice Universo (SEU)