Risk factors for primary and subsequent anal sphincter lacerations: A comparison of cohorts by parity and prior mode of delivery

To the Editors: I read with interest the article by J. L Lowder et al,1 and I would like to make the following comments. First, their recommendation of the vacuum extractor (VE) over forceps delivery in nulliparous women to lower the risk of anal sphincter laceration (ASL) overlooks the fact that these 2 instruments are not equivalent and thus cannot be used interchangeably. In fact, whereas the latter is used to actively deliver the baby (ie, to replace the vis a tergo), the former is used to augment, not replace, the natural forces of labor. My second observation relates to the obvious assumption by the authors that the association of ASL with forceps delivery, found in their retrospective review, proves causality. In fact, the simple observation that not all nulliparous women who undergo a forceps delivery suffer ASL, demonstrated the opposite. As most obstetricians properly trained in the use of this instrument will agree, forceps is not inherently dangerous. It becomes, however, a risk factor for this complication when excessive and inordinate traction is applied, a likely occurrence in the presence of unrecognized cephalopelvic disproportion (CPD), in concomitance with a median episiotomy. Therefore, I would not discourage the use of forceps, which can be resolutive when a cesarean section is either contraindicated by maternal conditions or preparation for it cannot be made in a timely fashion, and the VE cannot be used because it is either not suitable (artificial rotation) or downright contraindicated (preterm delivery, face or brow presentation, aftercoming head, suspected fetal coagulation defect, scalp sampling of fetal blood). Rather, I would recommend that before applying this instrument, every effort be made to rule out CPD and opt strictly for a mediolateral episiotomy, whose objective is precisely to reduce the likelihood of third-degree laceration.

Libertà sindacale e divieto di discriminazioni

L'A. analizza l'art. 15 dello Statuto dei Lavoratori e l'evoluzione dello stesso

Finalità dello sciopero

L'A. esamina la finalità dello sciopero - a fini contrattuali, di solidarietà, politico, ecc. - alla luce anche degli orientamenti della Corte costituzional

Light and Heavy Energy Refurbishments of Mediterranean Offices. Part I: Energy Audit of an Institutional Building on the Naples Coast

The public hand has a demonstrative role in matter of energy efficiency of owned or occupied buildings. Here, the energy audit of a high-rise university building is proposed. The methodology adopts the Cost-Optimal approach, as imposed by the European guidelines (EU Directive 2010/31/EU), based on feasibility studies performed with transient energy simulations. In particular, in situ surveys (infrared thermography and measurements of U-values) have been used for building, as detailed as possible, the building model for the numerical study. The analysis evidenced high-energy demands, mainly for the space heating and cooling. A second study discusses a cost-effective energy retrofit

Light and Heavy Energy Refurbishments of Mediterranean Offices. Part II: Cost-optimal Energy Renovation of an Institutional Building

A previous study has evidenced the poor energy performances of a building owned by the University of Naples Federico II. In detail, a reliable energy audit, by means of calibrated input, has been performed, and it revealed energy requests, polluting emissions and energy costs very high. By taking into consideration the exemplary role of the public hand, according to the EU Directives 2010/31/EE and 2012/27/EU, here a cost-optimal energy refurbishment is proposed, by analysing several energy efficiency measures, firstly singularly analysed and then combined in order to evaluate the super-positon effect

The Systemic Inflammatory Response Identifies Patients with Adverse Clinical Outcome from Immunotherapy in Hepatocellular Carcinoma

Systemic inflammation is a hallmark of cancer, and it has a pivotal role in hepatocellular carcinoma (HCC) development and progression. We conducted a retrospective study including 362 patients receiving immune check-point inhibitors (ICIs) across three continents, evaluating the influence of neutrophiles to lymphocytes ratio (NLR), platelets to lymphocytes ratio (PLR), and prognostic nutritional index (PNI) on overall (OS), progression free survival (PFS), and radiologic responses. In our 362 patients treated with immunotherapy, median OS and PFS were 9 and 3.5 months, respectively. Amongst tested inflammatory biomarkers, patients with NLR ≥ 5 had shorter OS (7.7 vs. 17.6 months, p < 0.0001), PFS (2.1 vs. 3.8 months, p = 0.025), and lower objective response rate (ORR) (12% vs. 22%, p = 0.034); similarly, patients with PLR ≥ 300 reported shorter OS (6.4 vs. 16.5 months, p < 0.0001) and PFS (1.8 vs. 3.7 months, p = 0.0006). NLR emerged as independent prognostic factors for OS in univariate and multivariate analysis (HR 1.95, 95%CI 1.45–2.64, p < 0.001; HR 1.73, 95%CI 1.23–2.42, p = 0.002) and PLR remained an independent prognostic factor for both OS and PFS in multivariate analysis (HR 1.60, 95%CI 1.6–2.40, p = 0.020; HR 1.99, 95%CI 1.11–3.49, p = 0.021). Systemic inflammation measured by NLR and PLR is an independent negative prognostic factor in HCC patients undergoing ICI therapy. Further studies are required to understand the biological mechanisms underlying this association and to investigate the predictive significance of circulating inflammatory biomarkers in HCC patients treated with ICIs