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

Nutraceuticals in fibroid management after ulipristal acetate administration: An observational study on patients' compliance

AbstractObjectiveOn May 13, 2020, the Italian government Pharmaceutical Agency (AIFA) stopped ulipristal acetate (UPA) treatments for uterine fibroids (UFs), so patients shifted to other natural treatments. The authors tested the patients' compliance with UF natural treatments.MethodsThirty patients of reproductive age (30–45 years) affected by UFs stopped UPA intake and started epigallocatechin gallate (EGCG) plus vitamin D3 treatment. Patients were asked to complete the Uterine Fibroid symptoms and Quality of Life (UFS‐QOL) questionnaire, divided into symptoms severity (SS) and health‐related quality of life (HRQL), after UPA suspension and to repeat it after 3 months of natural treatment. Collected data were analyzed using paired Student's t test, considering a P value less than 0.05 to be significant.ResultsThe SS score was significantly lower (–12.19%) for natural treatment when compared with UPA administration. The HRQL score significantly improved (+11.79%) after shifting treatment from UPA to natural therapy. All the investigated parameters appeared improved by 10% after the natural treatment. No adverse effects were reported following the natural treatment.ConclusionNatural treatments showed positive compliance in patients with UFs, based on HRQL score, representing an alternative therapeutic opportunity for patients forced to stop UPA therapy

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

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

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

Il ruolo del pubblico ministero nella Costituzione italiana

La Costituzione italiana ha trasformato in maniera innovativa il ruolo del pubblico ministero: da rappresentante del potere esecutivo presso l’autorità giurisdizionale, gerarchicamente sottoposto al Ministro della giustizia, che è tipico dei paesi di civil law , ad autonomo potere pubblico, titolare della pretesa punitiva dello Stato da esercitare obbligatoriamente nei casi stabiliti dalla legge e secondo le forme del giusto processo, e inserito nell’ambito dell’ordine giudiziario governato dal Csm. Nel volume, i principi costituzionali in tema di funzione requirente vengono quindi sviluppati sino a sostenere che, per rispettare appieno il ruolo che la Costituzione attribuisce al pubblico ministero di promotore a fini di giustizia dell’intervento decisorio del giudice, i poteri direttivi, che la riforma Castelli/Mastella conferisce al procuratore della Repubblica, devono essere interpretati in modo da rispettare la posizione di esclusiva sottoposizione alla legge costituzionalmente conforme, che è propria di ogni magistrato ordinario, compreso quello addetto alle funzioni requirenti. La ricerca si chiude difendendo i sempre attuali principi costituzionali sul pubblico ministero dai tentativi di stravolgimento operati con il disegno di legge costituzionale sulla giustizia presentato il 7 aprile 2011 dalle forze politiche di centro-destra.</jats:p