Impact of endometriosis on obstetric outcome after natural conception: a multicenter Italian study

Purpose To evaluate obstetric outcome in women with endometriosis who conceive naturally and receive standard obstetric care in Italy. Methods Cases 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. Results Three 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). Conclusion Women 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 registration Clinical trial registration number: NCT03354793

When more is not better: 10 'don'ts' in endometriosis management. An ETIC* position statement

41noETIC Endometriosis Treatment Italian ClubopenA 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.openAlio, L; Angioni, S; Arena, S; Bartiromo, L; Bergamini, V; Berlanda, N; Bonin, C; Busacca, M; Candiani, M; Centini, G; D’Alterio, M N; Di Cello, A; Exacoustos, C; Fedele, L; Frattaruolo, M P; Incandela, D; Lazzeri, L; Luisi, S; Maiorana, A; Maneschi, F; Martire, F; Massarotti, C; Mattei, A; Muzii, L; Ottolina, J; Perandini, A; Perelli, F; Pino, I; Porpora, M G; Raimondo, D; Remorgida, V; Seracchioli, R; Solima, E; Somigliana, E; Sorrenti, G; Venturella, R; Vercellini, P; Viganó, P; Vignali, M; Zullo, F; Zupi, EAlio, L; Angioni, S; Arena, S; Bartiromo, L; Bergamini, V; Berlanda, N; Bonin, C; Busacca, M; Candiani, M; Centini, G; D’Alterio, M N; Di Cello, A; Exacoustos, C; Fedele, L; Frattaruolo, M P; Incandela, D; Lazzeri, L; Luisi, S; Maiorana, Anna; Maneschi, F; Martire, F; Massarotti, C; Mattei, A; Muzii, L; Ottolina, J; Perandini, A; Perelli, F; Pino, Ida; Porpora, M G; Raimondo, D; Remorgida, V; Seracchioli, R; Solima, E; Somigliana, E; Sorrenti, G; Venturella, R; Vercellini, P; Vigano', Paola; Vignali, M; Zullo, F; Zupi,

Marathons and myasthenia gravis: a case report.

The cardinal symptoms of auto-immune myasthenia gravis are fatigue and weakness. Endurance events such as marathon running would seem incompatible with this chronic disease. Many patients stop sport altogether. There is limited literature of patients with auto-immune myasthenia gravis undergoing regular endurance exercise. We report the case of a 36-year-old female who began long-distance running whilst experiencing initial symptoms of myasthenia gravis. She was diagnosed with auto-immune myasthenia gravis and whilst advised to stop all sport, her way of fighting and living with this chronic and unpredictable disease was to continue running to maintain a healthy body and mind. Despite suffering from ocular, bulbar and localized limb fatigability, she managed to complete multiple marathons and achieve disease stability with cholinesterase inhibitors. Marathon and half-marathon running lead to distinct changes in mediators of inflammation in an exercise-dose-dependent manner. Despite symptoms of weakness and fatigue in certain muscles in myasthenia gravis, physical exertion remains possible and may not worsen symptoms as demonstrated in this case and recent studies. The immunomodulatory role of exercise could be considered in this case however this hypothesis remains to be confirmed in future studies with quantitative data

Non-exhaustive tests for critical power estimation

Objective The aim of this study was to propose a new method that allows for the estimation of critical power (CP) from non-exhaustive tests using ratings of perceived exertion (RPE). Methods Twenty-two subjects underwent two practice trials for ergometer and Borg 15-point scale familiarization, and adaptation to severe exhaustive exercise. After then, four exercise bouts were performed on different days for the estimation of CP and anaerobic work capacity (AWC) by linear work-time equation, and CP15, CP17, AWC15 and AWC17 were estimated using the work and time to attainment of RPE15 and RPE17 based on the Borg 15-point scale. Results The CP, CP15 and CP17 (170–177 W) were not significantly different (P > 0.05). However, AWC, AWC15 and AWC17 were all different from each other. The correlations between CP15 and CP17, with CP were strong (R = 0.871 and 0.911, respectively), but the AWC15 and AWC17 were not significantly correlated with AWC. Conclusion Sub-maximal RPE responses can be used for the estimation of CP from non-exhaustive exercise protocols

Critical power can be estimated from nonexhaustive tests based on rating of perceived exertion responses

The purpose of this study was to evaluate a novel procedure, based on the perceived exertion threshold (PET) concept, involving non-exhaustive tests (PET14–17) to estimate critical power (CP), as well as to examine the reproducibility of these indices. Twenty young men performed 2 trials (Trial 1 and Trial 2) of 4 exhaustive predictive tests to estimate CP, PET, and PET14–17. The slope coefficients of the regression lines corresponding to the ratings of perceived exertion (RPE) versus time relationship (y axis) obtained during the predictive tests were plotted against the power outputs (x axis) to estimate PET. PET was calculated as the intersection point of the regression line in the power axis. The 14–17 RPE range of each predictive test was modeled using the same mathematical procedures used to estimate PET14–17. CP was derived from the power-time hyperbolic equation. Analysis of variance revealed no significant differences among CP (189–194 W), PET (190–191 W) and PET14–17, (191–195 W). The correlations between CP and PET (r = 0.87), CP and PET14–17 (r = 0.89), and PET and PET14–17 (r = 0.88) were all strong. Additionally, the bias 6 limits of agreement when plotting CP and PET was –2.16 6 31.60 W, and –5.70 6 31.21 W when comparing CP and PET14–17. Relatively high reproducibility levels of CP (ICC = 0.96), PET (ICC = 0.85) and PET14–17 (ICC = 0.83) were recorded in the test-retest fashion. It can be concluded that the PET14–17 can be utilized with relatively high accuracy and reproducibility to estimate CP without causing exhaustion in the subjects

Quantitative MRCP assessment of pancreatic exocrine reserve and its correlation with faecal elastase-1 in patients with chronic pancreatitis

PURPOSE:This retrospective study was done to correlate a quantitative assessment of the pancreatic exocrine reserve by dynamic secretin magnetic resonance cholangiopancreatography (MRCPQ) with the faecal elastase-1 (FE-1) test in patients with chronic pancreatitis.MATERIALS AND METHODS:Thirty-five patients with a clinical diagnosis of chronic (CP) or acute recurrent (ARP) pancreatitis were enrolled. FE-1 was indicative of the pancreatic exocrine reserve. Subsequently, the patient population was subdivided into two groups according to a clinical threshold value of 200 \u3bcg/g. All patients underwent MRCP examination during secretin administration. Duodenal filling volume was calculated on T2-weigthed rapid acquisition with relaxation enhancement (RARE) MRCP images obtained 10 min after secretin injection. Duodenal filling volumes were compared with FE-1 values. Scatter plots, Pearson correlation coefficient and the Mann-Whitney U test were performed.RESULTS:Thirty-five paired MRCPQ-FE1 data sets were analysed. MRCPQ was significantly different (p=0.007) between patients with impaired and preserved pancreatic function; median and interquartile range (IQR) were 150.7 ml (137.3-205.5 ml; n=9) and 332.4 ml (190.6-506.9 ml; n=26). Both Pearson correlation coefficient (p<0.001) and the Mann-Whitney U test (p=0.007) were significant.CONCLUSIONS:MRCPQ significantly correlates with FE-1 values. It is possible to discriminate impaired and preserved pancreatic exocrine function using MRCPQ

Physiological and Perceived Exertion Responses at Intermittent Critical Power and Intermittent Maximal Lactate Steady State

Okuno, NM, Perandini, LAB, Bishop, D, Simões, HG, Pereira, G, Berthoin, S, Kokubun, E, and Nakamura, FY. Physiological and perceived exertion responses at intermittent critical power and intermittent maximal lactate steady state. J Strength Cond Res 25(7): 2053-2058, 2011—The aim of this study was to compare the power outputs of the intermittent critical power (CPi) with the intermittent maximal lactate steady state (MLSSi) and to compare the physiological and perceptual responses exercising at CPi and MLSSi. Ten subjects performed intermittent trials on a cycle ergometer to determine CPi and MLSSi using 30:30 seconds of effort and pause. The oxygen uptake (V̇o2), heart rate (HR), blood lactate concentration ([Lac]), and rating of perceived exertion (RPE) responses were compared during 30-minute cycling at CPi and MLSSi. The CPi (267 ± 45 W) was similar to MLSSi (254 ± 39 W), and they were correlated (r = 0.88; p < 0.05). The V̇o2 and HR responses stabilized throughout exercising at CPi (2.52 ± 0.52 L·min−1; 156 ± 8 b·min−1) and MLSSi (2.41 ± 0.32 L·min−1; 152 ± 10 b·min−1). These physiological variables were similar between conditions. However, the [Lac] and RPE were higher from the middle to the end of exercise duration at CPi ([Lac] = 6.9 ± 2.6 mM; RPE = 17.1 ± 2.1 a.u.) compared to MLSSi ([Lac] = 5.1 ± 0.9 mM; RPE = 15.7 ± 1.8 a.u.). Therefore, CPi intensity determined from 30:30 seconds of effort and rest periods on a cycle ergometer is equivalent to the MLSSi, and there is a physiological steady state throughout both exercise intensities, although the [Lac] and RPE responses at CPi are higher than at MLSSi. Thus, the CPi and MLSSi may be used as tools for intermittent training evaluation and prescription

Safety and possible effects of low-intensity resistance training associated with partial blood flow restriction in polymyositis and dermatomyositis

Abstract Introduction Our aim was to evaluate the safety and efficacy of a low-intensity resistance training program combined with partial blow flow restriction (BFR training) in a cohort of patients with polymyositis (PM) and dermatomyositis (DM). Methods In total, 13 patients with PM and DM completed a 12-week twice a week low-intensity (that is, 30% one-repetition-maximum (1RM)) resistance exercise training program combined with partial blood flow restriction (BFR). Assessments of muscle strength, physical function, quadriceps cross sectional (CSA) area, health-related quality of life, and clinical and laboratory parameters were assessed at baseline and after the intervention. Results The BFR training program was effective in increasing the maximal dynamic strength in both the leg-press (19.6%, P <0.001) and knee-extension exercises (25.2% P <0.001), as well as in the timed-stands (15.1%, P <0.001) and timed-up-and-go test (−4.5%, P =0.002). Quadriceps CSA was also significantly increased after the intervention (4.57%, P =0.01). Similarly, all of the components of the Short Form-36 Health Survey, the Health Assessment Questionnaire scores, and the patient- and physician reported Visual Analogue Scale were significantly improved after training (P <0.05). Importantly, no clinical evidence or any other self-reported adverse event were found. Laboratory parameters (creatine kinase and aldolase) were also unchanged (P >0.05) after the intervention. Conclusions We demonstrated that a 12-week supervised low-intensity resistance training program associated with partial blood flow restriction may be safe and effective in improving muscle strength and function as well as muscle mass and health-related quality of life in patients with PM and DM. Trial registration Clinicaltrials.gov NCT01501019 . Registered November 29, 2011

How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach

The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice