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Cataudella S, Lampis J, Busonera A, Congia F, Melis GB, Zavattini GC. From pregnancy to 3 months after birth:the beginning of mother-infant relationship from a maternal perspective. J Reprod Infant Psychol 2021; 40:266-287. [PMID: 34693840 DOI: 10.1080/02646838.2021.1995597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND An early positive mother-child relationship is a central factor in the development of a psychologically balanced personality. The study aims to identify risk and protective factors for the development of a balanced maternal-infant postnatal attachment. We explored the association between maternal-infant attachment and prenatal and postnatal variables potentially implicated in the development of this early bond: maternal-foetal prenatal attachment, social support, memories of parental care, romantic attachment, dyadic adjustment, parity, breastfeeding, planning pregnancy, woman's and infant's age, and difficulty of delivery. METHODS 123 pregnant women participated in the longitudinal study; they were assessed on the MAAS, PBI, ECR-R, MSPSS (t1: pregnancy), MPAS (t2: 3-months postnatally), DAS , and CES-D (t1, t2). RESULTS Four significant predictors of maternal-infant postnatal attachment (MPAS) emerged: maternal-foetal prenatal attachment (β = 0.379, p < .001), anxiety in the romantic relationships (β=-0.237, p=0.019), prenatal and postnatal dyadic adjustment (t1, β=-0.323, p=0.025 ;t2, β=0.329, p=0.014) in the couple's relationship. These variables explained 20.2% of variance in mother-infant attachment (R2adjusted=0.202). DISCUSSION The study highlights associations of maternal-infant postnatal attachment with prenatal and postnatal relational variables and with other variables related to the woman's reproductive and pregnancy history. Clinical attention to these factors could help protect the well-being of mother and child.
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Affiliation(s)
- Stefania Cataudella
- Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Cagliari, Italy
| | - Jessica Lampis
- Department of Pedagogy, Psychology, Philosophy, University of Cagliari, Cagliari, Italy
| | - Alessandra Busonera
- Department of Dynamic and Clinical Psychology, Sapienza, University of Rome, Italy
| | - Francesca Congia
- Department of Obstetrics and Gynecology, University Hospital of Cagliari (AOUCA), Cagliari, Italy
| | - Gian Benedetto Melis
- Department of Obstetrics and Gynecology, University Hospital of Cagliari (AOUCA), Cagliari, Italy
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Laurita Longo V, Odjidja EN, Beia TK, Neri M, Kielmann K, Gittardi I, Di Rosa AI, Boldrini M, Melis GB, Scambia G, Lanzone A. "An unnecessary cut?" multilevel health systems analysis of drivers of caesarean sections rates in Italy: a systematic review. BMC Pregnancy Childbirth 2020; 20:770. [PMID: 33302920 PMCID: PMC7731545 DOI: 10.1186/s12884-020-03462-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 11/26/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Improvements in medical technologies have seen over-medicalization of childbirth. Caesarean section (CS) is a lifesaving procedure proven effective in reducing maternal and perinatal mortality across the globe. However, as with any medical procedure, the CS intrinsically carries some risk to its beneficiaries. In recent years, CS rates have risen alarmingly in high-income countries. Many exceeding the World Health Organisation (WHO) recommendation of a 10 to 15% annual CS rate. While this situation poses an increased risk to women and their children, it also represents an excess human and financial burden on health systems. Therefore, from a health system perspective this study systematically summarizes existing evidence relevant to the factors driving the phenomenon of increasing CS rates using Italy as a case study. METHODS Employing the WHO Health System Framework (WHOHSF), this systematic review used the PRISMA guidelines to report findings. PubMed, SCOPUS, MEDLINE, Cochrane Library and Google Scholar databases were searched up until April 1, 2020. Findings were organised through the six dimensions of the WHOHSF framework: service delivery, health workforce, health system information; medical products vaccine and technologies, financing; and leadership and governance. RESULTS CS rates in Italy are affected by complex interactions among several stakeholder groups and contextual factors such as the hyper-medicalisation of delivery, differences in policy and practice across units and the national context, issues pertaining to the legal and social environment, and women's attitudes towards pregnancy and childbirth. CONCLUSION Mitigating the high rates of CS will require a synergistic multi-stakeholder intervention. Specifically, with processes able to attract the official endorsement of policy makers, encourage concensus between regional authorities and local governments and guide the systematic compliance of delivery units with its clinical guidelines.
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Affiliation(s)
- Valentina Laurita Longo
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy.
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK.
- Catholic University of Sacred Heart, 00168, Rome, Italy.
| | - Emmanuel Nene Odjidja
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Thierry Kamba Beia
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
- Health Services Department, Copperbelt University, Kitwe, Zambia
| | - Manuela Neri
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy
| | - Karina Kielmann
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Irene Gittardi
- Legal Department "Luca Santa Maria e associati", Via G. Serbelloni 1, 20122, Milan, Italy
| | - Amanda Isabella Di Rosa
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, EH21 6UU, Scotland, UK
| | - Michela Boldrini
- Department of Economics, University of Bologna, Piazza Antonio Scaravilli 2, 40126, Bologna, Italy
| | - Gian Benedetto Melis
- Department of Surgical Sciences, Department of Obstetrics and Gynaecology, University of Cagliari, SS 554 - bivio Sestu, Monserrato, 09032, Cagliari, Italy
| | - Giovanni Scambia
- Catholic University of Sacred Heart, 00168, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Antonio Lanzone
- Catholic University of Sacred Heart, 00168, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
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Neri M, Melis GB, Giancane E, Vallerino V, Pilloni M, Piras B, Loddo A, Paoletti AM, Mais V. Clinical Utility Of Elagolix As An Oral Treatment For Women With Uterine Fibroids: A Short Report On The Emerging Efficacy Data. Int J Womens Health 2019; 11:535-546. [PMID: 31695514 PMCID: PMC6815212 DOI: 10.2147/ijwh.s185023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 10/09/2019] [Indexed: 12/22/2022] Open
Abstract
Uterine fibroids (UFs) are the most common gynaecological benign disease. Even though often asymptomatic, UFs can worsen women’s health and their quality of life, causing heavy bleeding and anaemia, pelvic discomfort and reduced fertility. Surgical treatment of UFs could be limited by its invasiveness and the desire to preserve fertility. Thus, effective medical therapies for the management of this condition are needed. Common drugs used to control bleeding, such us hormonal contraceptive or levonorgestrel-releasing intrauterine system, have no effect on fibroids volume. Among other more efficient treatments, the gonadotropin-releasing hormone (GnRH) agonist or the selective progesterone-receptor modulators have a non-neutral safety profile; thus, they are used for limited periods or for cyclic treatments. Elagolix is a potent, orally bioavailable, non-peptide GnRH antagonist that acts by a competitive block of the GnRH receptor. The biological effect is a dose-dependent inhibition of gonadal axis, without a total suppression of estradiol concentrations. For this reason, even though comparative studies between elagolix and GnRH agonists have not been performed, elagolix has been associated with a better profile of adverse events. Recently, elagolix received US FDA approval for the treatment of moderate to severe pain caused by endometriosis. Several clinical trials assessed the efficacy of elagolix for the treatment of heavy bleeding caused by UFs and the definitive results of Phase III studies are expected. Available data on elagolix and UFs showed that the drug, with or without low-dose hormone add-back therapy, is able to significantly reduce menstrual blood loss, lead to amenorrhea and improve haemoglobin concentrations in the majority of participants in comparison with placebo. The safety and tolerability profile appeared generally acceptable. The concomitant use of add-back therapy can prevent bone loss due to the hypoestrogenic effect and can improve safety during elagolix treatment.
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Affiliation(s)
- Manuela Neri
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Gian Benedetto Melis
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Elena Giancane
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Valerio Vallerino
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Monica Pilloni
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Bruno Piras
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Alessandro Loddo
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Anna Maria Paoletti
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
| | - Valerio Mais
- Department of Obstetrics and Gynaecology, University of Cagliari, Italy.,Department of Surgical Sciences, University of Cagliari, Italy.,Maternal Child Department, University Hospital of Cagliari, Italy
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Tortorella L, Casarin J, Multinu F, Cappuccio S, McGree ME, Weaver AL, Langstraat CL, Keeney GL, Kumar A, Melis GB, Angioni S, Scambia G, Mariani A, Glaser GE. Sentinel lymph node biopsy with cervical injection of indocyanine green in apparent early-stage endometrial cancer: predictors of unsuccessful mapping. Gynecol Oncol 2019; 155:34-38. [DOI: 10.1016/j.ygyno.2019.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 12/27/2022]
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5
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Neri M, Pilloni M, Paoletti AM, Melis GB, Piras B, Ajossa S, Marotto MF, Corda V, Ronchi A, Giancane E, Vallerino V, Saba A, Zedda P, Orani MP, Cappai R, Coghe F, Mais V. Repeated two cycles of ulipristal acetate treatment improve the quality of life in premenopausal women with heavy menstrual bleeding dependent on uterine myomas, without impairment of bone health. Gynecol Endocrinol 2019; 35:756-761. [PMID: 30822182 DOI: 10.1080/09513590.2019.1576618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
This observational study was conducted in premenopausal women who presented themselves at the Obstetrics and Gynecology Department of the University Hospital of Cagliari (Italy), for heavy menstrual bleeding (HMB) dependent on uterine myomas. After a screening visit, 19 women without contraindications to ulipristal acetate (UPA) treatment, were included in the study that envisaged 12 months of observation in which each subject was asked to assume UPA (tablet of 5 mg, ESMYA®, one tablet a day for 3 months: first cycle) two menstrual cycles of interruption and a second ESMYA® cycle, followed by 3 months of observation (third follow-up month, visit 4). The significant decrease of myoma volume, diagnosed after the first ESMYA® cycle, persisted until the visit 4. The HMB significantly decreased during the ESMYA® treatment and persisted until visit 4. The quality of life (QoL), evaluated with the questionnaire SF-36, significantly improved during the study. The values of estradiol (E2), biochemical parameters of bone metabolism, as well as those of lumbar and hip bone mineral density, did not change during the study in comparison with basal levels. The efficacy of two repeated ESMYA® cycles to treat uterine myomas and their related symptoms improves the QoL without interfering with bone health.
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Affiliation(s)
- Manuela Neri
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Monica Pilloni
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Anna Maria Paoletti
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Gian Benedetto Melis
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Bruno Piras
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Silvia Ajossa
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Maria Francesca Marotto
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Valentina Corda
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Alessandro Ronchi
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Elena Giancane
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Valerio Vallerino
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Alessandra Saba
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Pierina Zedda
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Maria Paola Orani
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
| | - Riccardo Cappai
- c Laboratory Clinical Chemical Analysis and Microbiology, University Hospital of Cagliari , Cagliari , Italy
| | - Ferdinando Coghe
- c Laboratory Clinical Chemical Analysis and Microbiology, University Hospital of Cagliari , Cagliari , Italy
| | - Valerio Mais
- a Department of Surgical Sciences, University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology, University Hospital of Cagliari , Cagliari , Italy
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6
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Neri M, Peiretti M, Melis GB, Piras B, Vallerino V, Paoletti AM, Madeddu C, Scartozzi M, Mais V. Systemic therapy for the treatment of endometrial cancer. Expert Opin Pharmacother 2019; 20:2019-2032. [PMID: 31451034 DOI: 10.1080/14656566.2019.1654996] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Endometrial cancer (EC) is one of the most frequent gynecological cancers worldwide. The gold standard treatment of EC is most certainly surgery and may very well be the only therapy in the early stages of disease. To improve outcomes in non-early EC, adjuvant therapy is often employed but this is not standardized. Adjuvant options can include radiotherapy, chemotherapy or a combination of both. Adjuvant chemotherapy could be indicated in high-risk stage I and II or advanced stage EC. Several clinical trials are ongoing in an attempt to define the optimal adjuvant treatment. Furthermore, chemotherapy is the front-line therapy in advanced unresectable, metastatic or recurrent endometrial cancer. Areas covered: Herein, the authors review the first-line chemotherapy for the treatment of endometrial cancer and provide their expert perspectives on these therapies. Expert opinion: Chemotherapy is fundamental in advanced/recurrent EC. Further evidence is needed to characterize the role of adjuvant chemotherapy. Future studies should consider genomic and molecular heterogeneities to identify even more efficient tailored therapies.
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Affiliation(s)
- Manuela Neri
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
| | - Michele Peiretti
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
| | - Gian Benedetto Melis
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
| | - Bruno Piras
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
| | - Valerio Vallerino
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
| | - Anna Maria Paoletti
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
| | - Clelia Madeddu
- Department of Medical Oncology, Department of Internal Medicine, University of Cagliari , Monserrato , Italy
| | - Mario Scartozzi
- Department of Medical Oncology, Department of Internal Medicine, University of Cagliari , Monserrato , Italy
| | - Valerio Mais
- Department of Obstetrics and Gynaecology, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy.,Maternal Child Department, University Hospital of Cagliari , Monserrato , Italy
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7
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Saba L, Ajossa S, Ledda G, Balestrieri A, Schirru F, De Cecco CN, Suri JS, Melis GB, Lavra F, Guerriero S. Does the clinical information play a role in the magnetic resonance diagnostic confidence analysis of ovarian and deep endometriosis? Br J Radiol 2019; 92:20180548. [PMID: 30730754 DOI: 10.1259/bjr.20180548] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE: Some recent studies have explored how the experience in the observers change their performance in the endometriosis detection using MRI but the effects of the clinical information remains uncertain. The purpose of this study was to assess the effect of the clinical information in the diagnostic confidence in the MRI diagnosis of endometriosis. METHODS AND MATERIALS: Institutional Review Board was obtained. This study is compliant to STARD method. 80 patients (mean age 32 years; range 19 - 46 years) who had undergone MRI study and surgery for suspected endometriosis were retrospectively evaluated. MRI exams were performed with a 1.5 T scanner and the following five locations were assessed: ovary, anterior compartment, vaginal fornix, utero-sacral ligaments, and Rectum\Sigmoid\Pouch of Douglas. Data sets were evaluated twice on a 5-point scale by four radiologists with different level of expertise; the first time blinded to the clinical information and the second time, after 3 months together with the clinical chart. Statistical analysis included receiver operating characteristics curve analysis, the Cohen weighted test and sensitivity, specificity, positive predictive value, negative predictive value, accuracy, LR+ and LR-. RESULTS: A total of 140 localization of endometriosis (47 endometriomas and 93 endometriotic nodules) were found. The pairwise comparison demonstrated that in all cases the presence of clinical information improved the Az value. The concordance analysis indicated a mixed pattern from modest agreement (weighted κ value 0.556 for anterior compartment) to excellent agreement values (weighted κ value 0.867 for ovarian endometriomas). CONCLUSION: The results of our study suggest that clinical information is useful in diagnosing endometriosis in general anterior compartment, but not in other locations. Less experienced radiologists (resident) may benefit from it at utero-sacral ligaments or Rectum\Sigmoid\Pouch of Douglas. ADVANCES IN KNOWLEDGE: In this era of sometimes indiscriminate use of diagnostic methods, it is important to emphasis the context for interpretation of diagnostic results. Our paper confirms that clinical information is useful in diagnosing endometriosis.
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Affiliation(s)
- Luca Saba
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Silvia Ajossa
- 2 Department of Gynecology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Giuseppe Ledda
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Antonella Balestrieri
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Federica Schirru
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Carlo Nicola De Cecco
- 3 Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina , Charleston , United States
| | - Jasjit S Suri
- 4 Gynecological Diagnostic Division, Global Biomedical Technologies, Inc. , Roseville , United States
| | - Gian Benedetto Melis
- 2 Department of Gynecology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Francesco Lavra
- 1 Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
| | - Stefano Guerriero
- 2 Department of Gynecology, Azienda Ospedaliero Universitaria (A.O.U.) , Cagliari , Italy
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Loddo A, Cornacchia S, Cane FL, Barcellona D, Marongiu F, Melis GB, Angioni S, Paoletti AM, Neri M. Prophylaxis of peripartum haemorrhage using recombinant factor VIIa (rfVIIa) in pregnant women with congenital factor VII deficiency: A case report and literature review. Eur J Obstet Gynecol Reprod Biol 2019; 235:77-80. [PMID: 30831446 DOI: 10.1016/j.ejogrb.2019.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/04/2019] [Accepted: 02/17/2019] [Indexed: 12/19/2022]
Abstract
Congenital factor VII deficiency is a rare autosomal recessive disorder associated to different haemorrhagic manifestations. Labour and delivery may cause bleeding risk in patients with this coagulation deficit, thus it is appropriate to clarify whether prophylaxis of peripartum haemorrhage is necessary. To date, there are very few cases in scientific literature which report the management of women with congenital factor VII deficiency during labour, and a consensus for prophylaxis does not exist. In this manuscript we present the management of a 35 years old woman with factor VII deficiency, treated with recombinant factor VIIa before delivery, without haemorrhagic complications either for the woman and for the infant. Therefore, we present a review of similar cases managed with a peripartum prophylaxis with recombinant factor VIIa, and discuss its usefulness and effectiveness, in view of the severity of the deficit and the doses used.
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Affiliation(s)
- Alessandro Loddo
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy.
| | - Stefania Cornacchia
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Fiorenza Lo Cane
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Doris Barcellona
- Internal Medicine and Haemocoagulopathies Unit, University of Cagliari, Italy
| | - Francesco Marongiu
- Internal Medicine and Haemocoagulopathies Unit, University of Cagliari, Italy
| | - Gian Benedetto Melis
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Stefano Angioni
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Anna Maria Paoletti
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
| | - Manuela Neri
- Department of Surgical Sciences, Clinic of Obstetrics and Gynecology, University Hospital of Cagliari, Italy
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Multinu F, Casarin J, Tortorella L, Huang Y, Weaver A, Angioni S, Melis GB, Mariani A, Stewart EA, Laughlin-Tommaso SK. Incidence of sarcoma in patients undergoing hysterectomy for benign indications: a population-based study. Am J Obstet Gynecol 2019; 220:179.e1-179.e10. [PMID: 30447212 DOI: 10.1016/j.ajog.2018.11.1086] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/24/2018] [Accepted: 11/08/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Minimally invasive hysterectomy may require the use of morcellation to remove the uterus. In the presence of unexpected sarcoma, morcellation risks disseminating malignant cells and worsening survival outcomes. As a consequence, in 2014 the US Food and Drug Administration issued a black box warning against the use of power morcellator for the treatment of uterine fibroids. However, the proportion of unexpected sarcoma at the time of hysterectomy for presumed benign indication remains unclear. OBJECTIVE The objective of the study was to estimate the incidence of sarcoma among women undergoing hysterectomy for benign indication in Olmsted County, MN, between 1999 and 2013. STUDY DESIGN We conducted a population-based study including all hysterectomies performed for benign indication in Olmsted County women between Jan. 1, 1999, and Dec. 31, 2013. Cases were identified using the medical records-linkage system of the Rochester Epidemiology Project, and data were abstracted by a gynecologist who reviewed the complete medical records of each woman who underwent hysterectomy. An expert pathologist reviewed the pathologic slides of each sarcoma to ensure the accuracy of the diagnosis. Incidences of sarcoma (overall and by type of sarcoma) were estimated both overall and stratified by menopausal status, indication for surgery, and uterine weight as a rate per 100 persons. RESULTS A total of 4232 hysterectomies were performed during the study period. Among them, we identified 16 sarcomas, of which 11 (69%) were suspected preoperatively and 5 (31%) were unexpected. Of the total number of hysterectomies, 3759 (88.8%) were performed for benign indication. Among those, the incidence of unexpected sarcoma was 0.13% (5 per 3759 [95% confidence interval, 0.04-0.31%]). Uterine fibroids comprised 27.3% of all hysterectomies for benign indication (n = 1025) and was the indication most commonly associated with diagnosis of unexpected sarcoma. The incidence of unexpected sarcoma among surgeries for uterine fibroids was 0.35% (3 of 851) for premenopausal women and 0.57% (1 of 174) for peri/postmenopausal, and all 4 unexpected sarcomas were leiomyosarcoma. The incidence of unexpected sarcoma progressively increased with higher uterine weight with an incidence of 0.03% (1 of 2993) among women with a uterine weight <250 g vs 15.4% (2 of 13) with a uterine weight ≥2000 g. CONCLUSION Unexpected uterine sarcoma was low in all women undergoing hysterectomy for benign indication (0.13% or 1 in 752 surgeries) while it was increased in women with uterine fibroids (0.39% or 1 in 256 surgeries). Peri/postmenopausal women, women with large uteri, and age ≥45 years were risk factors for sarcoma.
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Melis GB, Piras B, Marotto MF, Neri M, Corda V, Vallerino V, Saba A, Lello S, Pilloni M, Zedda P, Paoletti AM, Mais V. The stimulation of the vaginal immune system with short-term administration of a vaginal gel containing fraction of Propionibacterium acnes, hyaluronic acid and polycarbophil is efficacious in vaginal infections dependent on disorders in the vaginal ecosystem. Gynecol Endocrinol 2018; 34:880-883. [PMID: 29648469 DOI: 10.1080/09513590.2018.1460345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
The vaginal immune system (VIS) is the first defense against antigens recognized as foreign. Substances capable of locally activating the VIS could be a valid strategy to treat vulvo-vaginal infections (VVI), caused by changes in the vaginal ecosystem, such as bacterial vaginosis (BV), vulvo-vaginal candidiasis (CA), and mixed vaginitis (MV). Bacterial lysates, obtained by crushing bacterial cultures, exert immuno-modulatory activities. The parietal fraction from Propionibacterium acnes is a patent of Depofarma (MoglianoVeneto, Italy). The preparation that associates such fraction to hyaluronic acid and polycarbophil is a registered trademark, commercially available in Italy as vaginal gel, Immunovag®. The study aimed to evaluate whether a 5-day-treatment with Immunovag® improves the symptoms and signs of VVI, in 60 women with Gardnerella vaginalis (GV), 154 with CA, 95 with MV, diagnosed with vulvar vaginal swab (VVS), and in 283 with BV, diagnosed with the Amsel criteria. At the end of the treatment (visit 2), the symptoms and signs of VVI disappeared in a significant number of subjects (χ2p < .02 vs pre-treatment) in all VVI groups, and their intensity was significantly (p < .0002) reduced in the subjects in which they were still present. Immunovag® represents a valid treatment of VVI induced by changes in the vaginal ecosystem.
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Affiliation(s)
- Gian Benedetto Melis
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Bruno Piras
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Maria Francesca Marotto
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Manuela Neri
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Valentina Corda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Valerio Vallerino
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Alessandra Saba
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Stefano Lello
- c Department of Health Protection for Women and Children , Gemelli Polyclinic Foundation, Rome , Italy
| | - Monica Pilloni
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Pierina Zedda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Anna Maria Paoletti
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Valerio Mais
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
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Neri M, Piras B, Paoletti AM, Vallerino V, Corda V, Ronchetti C, Taccori V, Pilloni M, Zedda P, Capobianco G, Dessole S, Melis GB, Mais V. Long-acting reversible contraception (LARC) with the intrauterine system with levonorgestrel (6 mcg/d): observational study on the acceptability, quality of life, and sexuality in Italian women. Gynecol Endocrinol 2018; 34:532-535. [PMID: 29254390 DOI: 10.1080/09513590.2017.1416465] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
This observational study was conducted in healthy premenopausal women, who presented themselves for contraception with an intrauterine system (IUS) releasing LNG (6 mcg/d) (Jaydess®, Bayer, Germany) at the outpatient Family Planning Clinics of the Departments of Obstetrics and Gynaecology of the Universities of Cagliari and Sassari (CA/SS), University-Hospitals of CA/SS (Italy). After a screening visit, 31 women without contraindications to Jaydess® were included in the study. No difficulty in Jaydess® insertion (Ji) was found in 87% of subjects, with pelvic pain (PP) (visual analogic scale, VAS:5.33 ± 2.54) reported by 27/31 subjects at the Ji. Pelvic pain was reported by 17/31 subjects on the first day (VAS: 3.07 ± 3.1), 16/31 subjects on the second day (VAS:2.37 ± 2.71), and 11/31 subjects on the third day (VAS:1.18 ± 2.02) from Ji, with a significant (p < .001) decrease in the intensity. The primary purposes of the study were to evaluate whether a 12-month-treatment (12-M-T) with Jaydess® interferes on either the quality of life (QoL) or sexuality. Jaydess® did not modify either QoL or sexuality in the 25 subjects who completed the 12-M-T. Throughout the 12-M-T, PP, or pregnancies were not found; the menstrual blood loss was significantly (p < .0001) reduced, and the intensity VAS of dysmenorrhea (#14 subjects) significantly (p < .001) improved.
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Affiliation(s)
- Manuela Neri
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Bruno Piras
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Anna Maria Paoletti
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Valerio Vallerino
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Valentina Corda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Camilla Ronchetti
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Valeria Taccori
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Monica Pilloni
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Pierina Zedda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Giampiero Capobianco
- c Department of Surgical, Microsurgical and Medical Sciences , University of Sassari , Sassari , Italy
- d Department of Obstetrics and Gynecology , University Hospital of Sassari (AOUSS) , Sassari , Italy
| | - Salvatore Dessole
- c Department of Surgical, Microsurgical and Medical Sciences , University of Sassari , Sassari , Italy
- d Department of Obstetrics and Gynecology , University Hospital of Sassari (AOUSS) , Sassari , Italy
| | - Gian Benedetto Melis
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Valerio Mais
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , Italy
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Melis GB, Neri M, Piras B, Paoletti AM, Ajossa S, Pilloni M, Marotto MF, Corda V, Saba A, Giancane E, Mais V. Vilaprisan for treating uterine fibroids. Expert Opin Investig Drugs 2018; 27:497-505. [DOI: 10.1080/13543784.2018.1471134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Gian Benedetto Melis
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Manuela Neri
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Bruno Piras
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Anna Maria Paoletti
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Silvia Ajossa
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Monica Pilloni
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Maria Francesca Marotto
- Dipartimento Materno Infantile, clinica ostetrica e ginecologica, policlinico universitario Duilio Casula, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Valentina Corda
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Alessandra Saba
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Elena Giancane
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
| | - Valerio Mais
- Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Azienda Ospedaliero Universitaria di Cagliari, Policlinico Universitario Duilio Casula, University of Cagliari, Italy
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Abstract
Hyperandrogenism is a condition affecting 5-10% of adolescents. The aim of this study was to evaluate the efficacy of very low dose of flutamide in the treatment of hyperandrogenism in adolescence. One hundred and fifty-eight patients, presenting severe acne and/or hirsutism, received 62.5 mg/day of flutamide + ethinylestradiol + gestodene for 18 months. The patients were subjected to assessments of hepatic enzymes levels. Thirty subjects treated with drospirenone + ethinylestradiol represented the control group. After 18 months of treatment, it was obtained a decrease of hirsutism (-39.9%), an almost recovery of acne (98% of patients) with better results of those obtained in control group. Only one case of light hypertransaminasemia was recorded, regressed spontaneously. Very low dose of flutamide was successful and safe and in the treatment of hyperandrogenism in adolescence.
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Affiliation(s)
- Anna Maria Fulghesu
- a Department of Obstetric and Gynecology , Univ di Cagliari , Cagliari , Italy
| | - Federica Melis
- a Department of Obstetric and Gynecology , Univ di Cagliari , Cagliari , Italy
| | - Giulia Murru
- b Department of Obstetrics and Gynecology , Ospedale San Paolo, Università di Milano , Milano , Italy
| | - Elena Canu
- a Department of Obstetric and Gynecology , Univ di Cagliari , Cagliari , Italy
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Abstract
Puropose To evaluate the feasibility of single port access laparoscopy (SPAL) for the treatment of ovarian endometrioma. Case Report Three patients affected by single ovarian endometrioma underwent cyst excision using a laparoendoscopic single port approach with a new multiport, reusable trocar, and flexible, curved and standard laparoscopic instruments. Results No conversion to multi-access standard laparoscopic technique was required and no intraoperative or postoperative complications were observed. The mean operative time was 40 minutes. Conclusions We conclude that single portal access laparoscopy is feasible, safe and effective for the excision of ovarian endometrioma, with good results in terms of cosmesis, postoperative pain and patient satisfaction. This approach may be indicated in patients with single cysts without dense adherences in the bowel and/or deep infiltrating endometriosis.
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Affiliation(s)
- Stefano Angioni
- Division of Gynecology, Obstetrics and
Pathophysiology of Human Reproduction, University of Cagliari - Italy
| | - Liliana Mereu
- Division of Gynecology, Villanova
Hospital, Firenze - Italy
| | - Giovanni Maricosu
- Division of Gynecology, Obstetrics and
Pathophysiology of Human Reproduction, University of Cagliari - Italy
| | - Luca Mencaglia
- Division of Gynecology, Villanova
Hospital, Firenze - Italy
| | - Gian Benedetto Melis
- Division of Gynecology, Obstetrics and
Pathophysiology of Human Reproduction, University of Cagliari - Italy
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Neri M, Malune ME, Corda V, Piras B, Zedda P, Pilloni M, Orani MP, Vallerino V, Melis GB, Paoletti AM. Body composition and psychological improvement in healthy premenopausal women assuming the oral contraceptive containing micronized estradiol (E2) and nomegestrol acetate (NOMAC). Gynecol Endocrinol 2017; 33:958-962. [PMID: 28485628 DOI: 10.1080/09513590.2017.1322574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
This observational study was conducted in healthy premenopausal women, who presented themselves for contraceptive advice at the outpatient Family Planning Clinics of the Department of Obstetrics and Gynecology of the University of Cagliari, Hospital-University of Cagliari (Italy). After a screening period of three menstrual cycles, 48 women without contraindications to estroprogestin contraceptives (OCs) were included in the study. The primary purposes of the study were to evaluate whether a 12-month-treatment with the combined OC containing micronized estradiol (1.5 mg, E2) plus nomegestrol acetate (2.5 mg, NOMAC) (E2/NOMAC) interfere on anthropometric indices (AI), body composition (BC) and psychological status (PS). In subjects with dysmenorrhea (#36), its intensity was evaluated using the visuo analogic scale (VAS), both before and during the 12-month-treatment with E2/NOMAC. E2/NOMAC did not modify neither AI nor BC in the 40 subjects who concluded the study. The PS and the VAS of dysmenorrhea were significantly (p < 0.0001) improved from the first cycle of treatment and throughout the E2/NOMAC treatment in comparison with basal values. The study suggests that E2/NOMAC is devoid of negative effects on AI and BC, with additional benefits on PS and dysmenorrhea.
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Affiliation(s)
- Manuela Neri
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Maria Elena Malune
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Valentina Corda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Bruno Piras
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Pierina Zedda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Monica Pilloni
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Maria Paola Orani
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Valerio Vallerino
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Gian Benedetto Melis
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
| | - Anna Maria Paoletti
- a Department of Surgical Sciences , University of Cagliari , Cagliari , Italy and
- b Department of Obstetrics and Gynecology at the University Hospital of Cagliari (AOUCA) , Cagliari , Italy
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Loddo A, D'Alterio MN, Neri M, Masala F, Cane FL, Melis GB. Pregnancy Complications After Hysteroscopic Metroplasty: A Ten-Year Case-Control Study. Surg Technol Int 2017; 30:205-209. [PMID: 28277599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Septate uterus is one of the most common congenital uterine anomalies and it may effect female reproductive health causing different obstetric complications, in particular miscarriages and reduction of fertility. MATERIALS AND METHODS We conducted a retrospective case-control (1:4) comparative study (Canadian Task Force Classification II-2) with the purpose to evaluate pregnancy complications (abnormal fetal presentations, preterm deliveries, and caesarean sections) and reproductive outcome after hysteroscopic metroplasty. We studied retrospectively two groups: 62 women that delivered after metroplasty (group A); and a control group of 248 women with no history of hysteroscopic metroplasty that delivered in the same period in our hospital (group B). RESULTS The rate of abnormal fetal presentations was significantly higher in study group A versus control group B (22.58% [14/62] vs. 4.03% [10/248], p<0.0001). Caesarean section rate was significantly higher in group A versus group B (66.12% [41/62] vs. 35.08% [87/248], p<0.0001), and preterm deliveries rate was significantly higher in group A versus group B (14.51% [9/62] vs. 6.45% [16/248], p= 0.037). Furthermore, in group A, we observed a significant reduction of the abortion rate and an increase in the total number of live births after metroplasty. CONCLUSIONS In our series of cases, we have observed a high rate of some pregnancy complications after metroplasty compared to the general population, such as preterm deliveries and fetal malpresentations with a higher rate of caesarean sections. Hysteroscopic metroplasty has been proven to improve the overall reproductive outcome by reducing miscarriage rate and increasing live birth rate. In our opinion, benefits obtained after metroplasty must be considered greater than the adverse pregnancy outcomes observed with our series.
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Affiliation(s)
- Alessandro Loddo
- Obstetrics-Gynecology Clinic and Pathophysiology of Human Reproduction Unit, Department of Surgical Sciences, University Hospital of Cagliari, Sardinia, Italy
| | - Maurizio Nicola D'Alterio
- Obstetrics-Gynecology Clinic and Pathophysiology of Human Reproduction Unit, Department of Surgical Sciences, University Hospital of Cagliari, Sardinia, Italy
| | - Manuela Neri
- Obstetrics-Gynecology Clinic and Pathophysiology of Human Reproduction Unit, Department of Surgical Sciences, University Hospital of Cagliari, Sardinia, Italy
| | - Francesca Masala
- Obstetrics-Gynecology Clinic and Pathophysiology of Human Reproduction Unit, Department of Surgical Sciences, University Hospital of Cagliari, Sardinia, Italy
| | - Fiorenza Lo Cane
- Obstetrics-Gynecology Clinic and Pathophysiology of Human Reproduction Unit, Department of Surgical Sciences, University Hospital of Cagliari, Sardinia, Italy
| | - Gian Benedetto Melis
- Obstetrics-Gynecology Clinic and Pathophysiology of Human Reproduction Unit, Department of Surgical Sciences, University Hospital of Cagliari, Sardinia, Italy
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Seitz C, Bumbuliene Ž, Costa AR, Heikinheimo O, Heweker A, Hudeček R, Jacquemyn Y, Melis GB, Parashar P, Rechberger T, Sánchez AC, van Aken B, Zatik J, Gemzell-Danielsson K. Rationale and design of ASTEROID 2, a randomized, placebo- and active comparator-controlled study to assess the efficacy and safety of vilaprisan in patients with uterine fibroids. Contemp Clin Trials 2017; 55:56-62. [DOI: 10.1016/j.cct.2017.02.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 02/02/2017] [Accepted: 02/04/2017] [Indexed: 12/13/2022]
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Melis GB, Neri M, Corda V, Malune ME, Piras B, Pirarba S, Guerriero S, Orrù M, D'Alterio MN, Angioni S, Paoletti AM. Overview of elagolix for the treatment of endometriosis. Expert Opin Drug Metab Toxicol 2017; 12:581-8. [PMID: 27021205 DOI: 10.1517/17425255.2016.1171316] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Suppression of sex-steroid secretion is required in a variety of gynecological conditions. This can be achieved using gonadotropin releasing hormone (GnRH) agonists that bind pituitary gonadotropin receptors and antagonize the link-receptor of endogenous GnRH, inhibiting the mechanism of GnRH pulsatility. On the other hand, GnRH antagonists immediately reduce gonadal steroid levels, avoiding the initial stimulatory phase of the agonists. Potential benefits of GnRH antagonists over GnRH agonists include a rapid onset and reversibility of action. Older GnRH antagonists are synthetic peptides, obtained by modifications of certain amino acids in the native GnRH sequence. They require subcutaneous injections, implantation of long-acting depots. The peptide structure is responsible for histamine-related adverse events and the tendency to elicit hypersensitivity reactions. AREAS COVERED Research has worked towards the development of non-peptidic molecules exerting antagonist action on GnRH. They are available for oral administration and may have a more beneficial safety profile in comparison with peptide GnRH antagonists. This article focuses on the data of the literature about elagolix, a novel non-peptidic GnRHantagonist, in the treatment of endometriosis. EXPERT OPINION Elagolix demonstrated efficacy in the management of endometriosis-associated pain and had an acceptable safety and tolerability profile. However, further studies are necessary to evaluate its non-inferiority in comparison with other endometriosis's treatments.
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Affiliation(s)
- Gian Benedetto Melis
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Manuela Neri
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Valentina Corda
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Maria Elena Malune
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Bruno Piras
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Silvia Pirarba
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Stefano Guerriero
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Marisa Orrù
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Maurizio Nicola D'Alterio
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Stefano Angioni
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
| | - Anna Maria Paoletti
- a Clinica Ostetrica e Ginecologica, Dipartimento di Scienze Chirurgiche , Università di Cagliari , Cagliari , Italy.,b Clinica Ostetrica e Ginecologica , Azienda Ospedaliero Universitaria di Cagliari, Policlinico Duilio Casula , Monserrato , Italy
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Pontis A, Sedda F, Mereu L, Podda M, Melis GB, Pisanu A, Angioni S. Review and meta-analysis of prospective randomized controlled trials (RCTs) comparing laparo-endoscopic single site and multiport laparoscopy in gynecologic operative procedures. Arch Gynecol Obstet 2016; 294:567-77. [DOI: 10.1007/s00404-016-4108-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/22/2016] [Indexed: 12/31/2022]
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Guerriero S, Saba L, Alcazar JL, Pascual MA, Ajossa S, Perniciano M, Piras A, Sedda F, Peddes C, Fabbri P, Pilla F, Zajicek M, Giuseppina P, Melis GB. Past, present and future ultrasonographic techniques for analyzing ovarian masses. ACTA ACUST UNITED AC 2016; 11:369-83. [PMID: 26102474 DOI: 10.2217/whe.15.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Ultrasonography is today the method of choice for distinguishing between benign and malignant adnexal pathologies. Using pattern recognition several types of tumors can be recognized according to their characteristic appearance on gray-scale imaging. Color Doppler imaging should be used only to perform a semiquantitative color score or evaluate the flow location. International Ovarian Tumor Analysis group had standardized definitions characterizing adnexal masses and suggested the use of 'simple rules' in premenopausal women. Recently, the use of 3D vascular indices has been proposed but its potential use in clinical practice is debated. Also computerized aided diagnosis algorithms showed encouraging results to be confirmed in the future.
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Affiliation(s)
- Stefano Guerriero
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Luca Saba
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Juan Luis Alcazar
- Department of Obstetrics & Gynecology, University of Navarra, Pamplona, Spain
| | | | - Silvia Ajossa
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Maura Perniciano
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Alba Piras
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Federica Sedda
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Cristina Peddes
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Paola Fabbri
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Federica Pilla
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
| | - Michal Zajicek
- Department of Obstetrics & Gynecology, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Parodo Giuseppina
- Department of Obstetrics & Gynecology, University of Cagliari, Cagliari, Italy
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Paoletti AM, Lello S, Di Carlo C, Orrù M, Malune ME, Neri M, Pilloni M, Zedda P, D'Alterio MN, Motzo C, Melis GB, Cagnacci A. Effect of Estradiol valerate plus dienogest on body composition of healthy women in the menopausal transition: a prospective one-year evaluation. Gynecol Endocrinol 2016; 32:61-4. [PMID: 26370625 DOI: 10.3109/09513590.2015.1079175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
In the menopausal transition (MT), combined oral contraceptive (COC) should be chosen accordingly to its neutrality on liver metabolism and to its ability to counter the increase of fat mass (FM) that occurs in this reproductive period of life. This prospective multi-centric observational study was conducted on 36 women in their MT at the Universities of Cagliari, Modena and Naples. The body weight (BW), the Body Mass Index (BMI), the waist to hip ratio (WHR), the measurement of body composition (BC) with the Multi-frequency Bioelectrical Impedance (MF-BIA) were performed before, at the 6th and at the 12th month of the study in which a group of women (control group; N.18) did not assume COC, whereas the other 18 women assumed the four-phasic COC containing estradiol valerate (EV) associated with dienogest (EV/DNG group). In comparison to controls in the EV/DNG group, a significant decrease (p < 0.05) of BW (58.8 ± 7.6 to 57.3 ± 7.0), BMI (24.1 ± 2.7 to 23.5 ± 2.8), WHR (0.82 ± 0.052 to 0.79 ± 0.048) and FM (17.7 ± 5.4 to 16.4 ± 5.6) was observed. In controls, FM significantly increased (17.0 ± 11 to 17.7 ± 2.7; p < 0.05). In conclusion, these results suggest that the anti-androgenic and progestinic activities of DNG associated with a weak estrogenic activity of EV, is a contraceptive method capable of counteracting the negative changes of BC occurring in the MT.
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Affiliation(s)
- Anna Maria Paoletti
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Stefano Lello
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Costantino Di Carlo
- b Clinica Ostetrica e Ginecologica, Università di Napoli Federico II , Napoli , Italy , and
| | - Marisa Orrù
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Maria Elena Malune
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Manuela Neri
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Monica Pilloni
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Pierina Zedda
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Maurizio Nicola D'Alterio
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Costantino Motzo
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Gian Benedetto Melis
- a Dipartimento di Scienze Chirurgiche, Clinica Ostetrica e Ginecologica, Università di Cagliari, Azienda Ospedaliero Universitaria (AOU) di Cagliari , Cagliari , Italy
| | - Angelo Cagnacci
- c Department of Obstetrics and Pediatrics, Obstetrics and Gynecology , Azienda Policlinico of Modena , Modena , Italy
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Guerriero S, Ajossa S, Minguez JA, Jurado M, Mais V, Melis GB, Alcazar JL. Accuracy of transvaginal ultrasound for diagnosis of deep endometriosis in uterosacral ligaments, rectovaginal septum, vagina and bladder: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2015; 46:534-545. [PMID: 26250349 DOI: 10.1002/uog.15667] [Citation(s) in RCA: 144] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 07/27/2015] [Accepted: 08/03/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To review the diagnostic accuracy of transvaginal ultrasound (TVS) in the preoperative detection of endometriosis in the uterosacral ligaments (USL), rectovaginal septum (RVS), vagina and bladder in patients with clinical suspicion of deep infiltrating endometriosis (DIE). METHODS An extensive search was performed in MEDLINE (PubMed) and EMBASE for studies published between January 1989 and December 2014. Studies were considered eligible if they reported on the use of TVS for the preoperative detection of endometriosis in the USL, RVS, vagina and bladder in women with clinical suspicion of DIE using the surgical data as a reference standard. Study quality was assessed using the PRISMA guidelines and QUADAS-2 tool. RESULTS Of the 801 citations identified, 11 studies (n = 1583) were considered eligible and were included in the meta-analysis. For detection of endometriosis in the USL, the overall pooled sensitivity and specificity of TVS were 53% (95%CI, 35-70%) and 93% (95%CI, 83-97%), respectively. The pretest probability of USL endometriosis was 54%, which increased to 90% when suspicion of endometriosis was present after TVS examination. For detection of endometriosis in the RVS, the overall pooled sensitivity and specificity were 49% (95%CI, 36-62%) and 98% (95%CI, 95-99%), respectively. The pretest probability of RVS endometriosis was 24%, which increased to 89% when suspicion of endometriosis was present after TVS examination. For detection of vaginal endometriosis, the overall pooled sensitivity and specificity were 58% (95%CI, 40-74%) and 96% (95%CI, 87-99%), respectively. The pretest probability of vaginal endometriosis was 17%, which increased to 76% when suspicion of endometriosis was present after TVS assessment. Substantial heterogeneity was found for sensitivity and specificity for all these locations. For detection of bladder endometriosis, the overall pooled sensitivity and specificity were 62% (95%CI, 40-80%) and 100% (95%CI, 97-100%), respectively. Moderate heterogeneity was found for sensitivity and specificity for bladder endometriosis. The pretest probability of bladder endometriosis was 5%, which increased to 92% when suspicion of endometriosis was present after TVS assessment. CONCLUSION Overall diagnostic performance of TVS for detecting DIE in uterosacral ligaments, rectovaginal septum, vagina and bladder is fair with high specificity.
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Affiliation(s)
- S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - S Ajossa
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - J A Minguez
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - M Jurado
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - V Mais
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - G B Melis
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - J L Alcazar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
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Caboni P, Meloni A, Lussu M, Carta E, Barberini L, Noto A, Deiana SF, Mereu R, Ragusa A, Paoletti AM, Melis GB, Fanos V, Atzori L. Urinary metabolomics of pregnant women at term: a combined GC/MS and NMR approach. J Matern Fetal Neonatal Med 2015; 27 Suppl 2:4-12. [PMID: 25284171 DOI: 10.3109/14767058.2014.956403] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Physiological changes leading to parturition are not completely understood while clinical diagnosis of labour is still retrospective. Gas chromatography mass spectrometry (GC/MS) and nuclear magnetic resonance spectroscopy (NMR) represent two of the main analytical platforms used in clinical metabolomics. Metabolomics might help us to improve our knowledge about the biochemical mechanisms underlying labour. METHODS Urine samples (n = 59), collected from pregnant women at term of gestation before and/or after the onset of labour, were analysed by GC/MS and NMR techniques in order to identify the metabolic profile. Both GC/MS and NMR data matrices containing the identified metabolites were analysed by multivariate statistical techniques in order to characterise the discriminant variables between labour (L) and not labour (NL) status. RESULTS 18 potential metabolites (11 with (1)H-NMR, eight with GC-MS: glycine was relevant in both) were found discriminant in urine of women during labour. Taken together, the identified metabolites produced a composite biomarker pattern, a sort of barcode, capable of differentiating between labour and not labour conditions. Major discriminant metabolites for NMR and GC/MS analysis were: alanine, glycine, acetone, 3-hydroxybutiyric acid, 2,3,4-trihydroxybutyric acid and succinic acid, giving a urine metabolite signature on the late phase of labour. CONCLUSIONS The metabolomics analysis evidenced clusters of metabolites involved in labour condition able to discriminate between urine samples collected before the onset and during labour, potentially offering the promise of a robust screening test.
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Affiliation(s)
- Pierluigi Caboni
- Department of Life and Environmental Sciences, University of Cagliari , Cagliari , Italy
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Abstract
Deep endometriosis involvement of the bladder is uncommon but it is symptomatic in most of the cases. Although laparoscopic excision is very effective, some patients with no pregnancy desire require a medical approach. We performed a pilot study on the effect of a new progestin dienogest on bladder endometriosis. Six patients were treated for 12 months with dienogest 2 mg/daily. Pain, urinary symptoms, quality of life, nodule volume and side effects were recorded. During treatment, symptoms improved very quickly and the nodules exhibit a remarkable reduction in size. Dienogest may be an alternative approach to bladder endometriosis.
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Affiliation(s)
- Stefano Angioni
- Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari , Monserrato , Italy
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Paoletti AM, Cagnacci A, Di Carlo C, Orrù MM, Neri M, D'Alterio MN, Melis GB. Clinical effect of hormonal replacement therapy with estradiol associated with noretisterone or drospirenone. A prospective randomized placebo controlled study. Gynecol Endocrinol 2015; 31:384-7. [PMID: 25703254 DOI: 10.3109/09513590.2014.1003294] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The study was performed to compare the clinical effect of a hormone replacement therapy (HRT) with two different progestins. Postmenopausal women (PMW) with climacteric symptoms (CS) randomly received for 12 months orally, either placebo (n = 20), 1 mg estradiol (E) plus 0.5 mg noretisterone acetate (NETA; n = 40), or 2 mg drospirenone (DRSP; n = 40), a testosterone- and spironolactone-derived molecule, respectively. Weight (W) declined only during E/DRSP (p < 0.04 versus placebo). Fat mass (FM) decreased, similarly, during E/NETA and E/DRSP. Intracellular water (ICW) did not change, while extracellular water (ECW) decreased during E/DRSP (p < 0.0001) (p < 0.002 versus E/NETA). During E/NETA and E/DRSP, similar decreases were observed for insulin resistance (IR) by the homeostatic model assessment for IR (HOMA-IR) (p < 0.0001 versus placebo for both), systolic (p < 0.04 versus placebo for both) and diastolic (p < 0.002) blood pressure (BP). Lipids did not change. In comparison to placebo CS, by the Kupperman Index (KI), significantly declined (p < 0.0001) during E/NETA or E/DRSP. Menopause-specific Quality of Life (MENQoL) significantly declined versus placebo (p < 0.04) during both E/NETA and E/DRSP. In conclusion, differences between the two progestins are mainly limited to body composition (BC), where the addition of DRSP decreases ECW and body W (BW).
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Affiliation(s)
- Anna Maria Paoletti
- Department of Obstetrics and Gynecology, University Of Cagliari, Policlinico Universitario Duilio Casula, Monserrato , Cagliari , Italy
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Abstract
Several imaging options are available today to diagnose endometriosis. Currently, the two techniques most used are sonography and magnetic resonance imaging (MRI). Three-dimensional (3D) sonography has proved to be particularly sensitive in the diagnosis of endometriosis. In recent years, MRI has emerged as a high reproducible method to explore endometriosis; moreover, its capability to evaluate tissue signal is an extremely powerful system in the differential diagnosis with other pathologies and for the identification of malignant degeneration. The purpose of this paper is to present the state-of-the-art of MRI of endometriosis by performing a review of the literature and showing the epidemiology, pathogenesis, and classification of endometriosis. In this work, the technique that should be used, MR findings of endometriosis and the principles of differential diagnosis are explained.
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Monserrato, Italy
| | - Rosa Sulcis
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Monserrato, Italy
| | - Gian Benedetto Melis
- Department of Gynecology, Azienda Ospedaliero Universitaria (A.O.U.), Monserrato, Italy
| | - Carlo Nicola de Cecco
- Departments of Radiological Sciences, Oncology, and Pathology, University of Rome Sapienza, Latina, Italy
| | - Andrea Laghi
- Departments of Radiological Sciences, Oncology, and Pathology, University of Rome Sapienza, Latina, Italy
| | - Mario Piga
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Monserrato, Italy
| | - Stefano Guerriero
- Department of Gynecology, Azienda Ospedaliero Universitaria (A.O.U.), Monserrato, Italy
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Abstract
Infertility is a common problem in patients with endometriosis and the involved mechanisms are still not completely known. The management of infertility in endometriosis patients includes surgery as well as assisted reproductive technology. Laparoscopic surgery has shown better results in infertility patients with endometriosis in comparison to laparotomy procedures. Laparoscopic surgery has proposed benefits in both minimal to moderate diseases. However, while there may be some benefits with severe diseases, there is still not enough evidence to recommend laparoscopic surgery as the recommended surgery when the main goal is to obtain fertility. We performed a MEDLINE search for articles on fertility in women with deep infiltrating endometriosis (DIE) published between 1990 and April 2015 using the following keywords: "endometriosis", "deep infiltrative endometriosis", "infertility", "fertility after surgery", "laparoscopy surgery", "laparotomy", "pregnancy", "fertility outcome", "bladder endometriosis", and "ureteral endometriosis". The aim of this review was to analyze the results of available clinical studies (randomized controlled or not controlled studies; retrospective cohort studies; or case-control and prospective studies) and guidelines on surgical treatment of infertile endometriosis patients, and pregnancy outcomes after surgery.
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Affiliation(s)
- Stefano Angioni
- a Division of Gynecology and Obstetrics, Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
| | - Vito Cela
- b Division of Gynecology and Obstetrics, Department of Surgical Sciences , University of Pisa , Italy , and
| | - Federica Sedda
- a Division of Gynecology and Obstetrics, Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
| | - Emanuela Stochino Loi
- a Division of Gynecology and Obstetrics, Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
| | - Vito Cofelice
- a Division of Gynecology and Obstetrics, Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
| | | | - Gian Benedetto Melis
- a Division of Gynecology and Obstetrics, Department of Surgical Sciences , University of Cagliari , Cagliari , Italy
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Affiliation(s)
- A Pontis
- Division of Gynaecology and Obstetrics, University of Cagliari, Cagliari, Italy
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Guerriero S, Alcazar JL, Pilloni M, Ajossa S, Olartecoechea B, Sedda F, Piras A, Melis GB, Saba L. Reproducibility of two different methods for performing mean gray value evaluation of cyst content in endometriomas using VOCAL. J Med Ultrason (2001) 2014; 41:325-32. [PMID: 27277906 DOI: 10.1007/s10396-013-0514-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 10/21/2013] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To compare two different methods (manual sampling of the entire cyst and semi-automated spherical sampling from the central part of the cyst) for calculating the mean gray value (MGV) from the cystic content in endometriomas using virtual organ computer-aided analysis (VOCAL). METHODS Forty-one volumes from histologically confirmed endometriomas were retrieved from our database and the volumes were analyzed to compare the MGVs obtained via the two modalities. In addition, to evaluate the reproducibility in a sample of 20 volumes, two different observers calculated the MGV from cyst content using VOCAL software. For each method, each examiner analyzed the volumes twice, 3 weeks apart, for assessment of intra-observer agreement. First, manual sampling of the internal contour of all the cysts was performed, and 1 week later semi-automated 2-cm sphere sampling from the central part of the cyst was carried out. In addition, the observers recorded the time spent performing each analysis. Inter- and intra-observer reproducibility was evaluated for each method using intra-class correlation coefficients (ICC). RESULTS There was no difference in the mean MGV between manual sampling (22.211 ± 7.541) and the semi-automated modality of sampling (23.840 ± 8.621, p = 0.439). The correlation between manual and semi-automated sampling measurement was high (r = 0.92). According to the ICCs, there was no significant difference in interobserver reliability between manual sampling (0.931; 95 % CI, 0.824-0.973) and the semi-automated modality of sampling (0.924; 95 % CI, 0.809-0.970). Intra-observer reproducibility for both examiners was good (ICC > 0.94). Semi-automated measurements were obtained faster than those obtained by manual evaluation (p = 0.0001 for observer 1 and p = 0.083 for observer 2). CONCLUSIONS Both methods seem to be reliable, but the semi-automated method using the sphere should be preferred because it is a less time-consuming procedure.
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Affiliation(s)
- Stefano Guerriero
- Department of Obstetrics and Gynaecology, Ospedale San Giovanni di Dio, University of Cagliari, Via Ospedale 46, 09124, Cagliari, Italy.
| | - Juan Luis Alcazar
- Clinica Universitaria de Navarra, University of Navarra, Pamplona, Spain
| | - Monica Pilloni
- Department of Obstetrics and Gynaecology, Ospedale San Giovanni di Dio, University of Cagliari, Via Ospedale 46, 09124, Cagliari, Italy
| | - Silvia Ajossa
- Department of Obstetrics and Gynaecology, Ospedale San Giovanni di Dio, University of Cagliari, Via Ospedale 46, 09124, Cagliari, Italy
| | | | - Federica Sedda
- Department of Obstetrics and Gynaecology, Ospedale San Giovanni di Dio, University of Cagliari, Via Ospedale 46, 09124, Cagliari, Italy
| | - Alba Piras
- Department of Obstetrics and Gynaecology, Ospedale San Giovanni di Dio, University of Cagliari, Via Ospedale 46, 09124, Cagliari, Italy
| | - Gian Benedetto Melis
- Department of Obstetrics and Gynaecology, Ospedale San Giovanni di Dio, University of Cagliari, Via Ospedale 46, 09124, Cagliari, Italy
| | - Luca Saba
- AOU of Cagliari, University of Cagliari, Cagliari, Italy
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Guerriero S, Ajossa S, Gerada M, Virgilio B, Pilloni M, Galvan R, Laparte MC, Alcázar JL, Melis GB. Transvaginal ultrasonography in the diagnosis of extrauterine pelvic diseases. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.6.731] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Paoletti AM, Orrù MM, Marotto MF, Pilloni M, Zedda P, Fais MF, Piras B, Piano C, Pala S, Lello S, Coghe F, Sorge R, Melis GB. Observational study on the efficacy of the supplementation with a preparation with several minerals and vitamins in improving mood and behaviour of healthy puerperal women. Gynecol Endocrinol 2013; 29:779-83. [PMID: 23782001 DOI: 10.3109/09513590.2013.801447] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We investigated whether a formulation containing vitamins and minerals (vit&min) could improve the worsening of mood changes occurring after delivery ("a.d."). The study was performed in 552 healthy non-anaemic puerperal women ("p.w") without risk factors for puerperal depression ("p.d"). They were at their first full-term pregnancy, and spontaneously delivered healthy newborns. The Edinburgh Depression Postnatal scale (EPDS) evaluates the psychological status of "p.w". EPDS was administered the 3rd (visit 1), 15th (visit 2) and 30th (visit 3) day "a.d.". An EPDS >12 indicates a major susceptibility to "p.d". At the same time intervals, haemoglobin, iron and ferritin (haematological parameters) levels were evaluated. After visit 1, the subjects were randomized to vit&min treatment (group A; N.274) or to calcium/vitamin D3 treatment (group B; N.278). In both groups haematological parameters significantly increased without differences between the groups. EPDS score improved in both groups, but in the group A, the EPDS decrease was significantly larger (p < 0.05) in comparison to the group B. This effect is mainly evident in subjects with a basal EPDS ≥ 12. An early examination of psychological condition could select "p.w." with a high susceptibility to neuronal changes occurring postpartum. Vit&min favourably modulates brain functions antagonizing the evolution to "p.d".
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Affiliation(s)
- Anna Maria Paoletti
- Department of Obstetrics and Gynaecology, University of Cagliari, University Hospital of Cagliari, Cagliari, Italy.
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Guerriero S, Pilloni M, Alcazar JL, Sedda F, Ajossa S, Mais V, Melis GB, Saba L. Tissue characterization using mean gray value analysis in deep infiltrating endometriosis. Ultrasound Obstet Gynecol 2013; 41:459-464. [PMID: 22915525 DOI: 10.1002/uog.12292] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/31/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To investigate differences in tissue characterization using three-dimensional sonographic mean gray value (MGV) between retrocervical and rectosigmoid deeply infiltrating endometriosis, and to assess intra- and interobserver concordance in MGV quantification. METHODS In this retrospective study, stored ultrasound volumes from 50 premenopausal women (mean age, 32 years) with 57 histologically confirmed nodules of deep endometriosis were retrieved from our database for analysis. A single experienced operator had acquired all volumes. For each nodule, the MGV was evaluated using virtual organ computer-aided analysis (VOCAL) software with semiautomated sphere-sampling (1 cm3) from the central part of the nodule. In these patients the MGV was also quantified from the myometrium of the fundal part of the uterus. In addition, two observers calculated the MGV in a subset of 24 volumes in order to quantify inter- and intraobserver agreement using intraclass correlation coefficients (ICC). RESULTS Mean MGV was significantly higher in rectosigmoid nodules (n = 34) than in nodules with a retrocervical location (n = 23) (23.863 vs. 17.705; P < 0.001). MGV of the myometrium was significantly higher in comparison with that of nodules in both locations (P < 0.001 for both). Intra- and interobserver measurement reproducibility was excellent (ICC > 0.95). CONCLUSIONS Retrocervical and rectosigmoid endometriotic nodules display significantly different MGVs. Measurement of MGV is highly reproducible and its clinical value in the diagnosis and assessment of distribution of deep endometriosis should be assessed in future studies.
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Affiliation(s)
- S Guerriero
- Department of Obstetrics and Gynaecology, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
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Guerriero S, Spiga S, Ajossa S, Peddes C, Perniciano M, Soggiu B, De Cecco CN, Laghi A, Melis GB, Saba L. Role of imaging in the management of endometriosis. Minerva Ginecol 2013; 65:143-166. [PMID: 23598781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The imaging techniques have a fundamental role in the diagnosis of endometriosis. Ovarian endometriosis (endometrioma) and deep endometriosis can be recognized using transvaginal ultrasound and/or magnetic resonance imaging (MRI). Although transvaginal ultrasound is the first choice of imaging modality when investigating women with pelvic pain, MRI have a role for the wider field of visions. The reproducibility of both techniques has been investigated. The three-dimensional ultrasonography has been proposed. Also studies regarding unusual localizations are reported in the literature. New insights are present about the role of imaging in the detection of the malignant transformations. This review summarizes the current evidence on the diagnostic accuracy of these two techniques in the pre-surgical assessment of endometriosis.
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Affiliation(s)
- S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.
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Melis GB, Piras B, Marotto MF, Orru' MM, Maricosu G, Pilloni M, Guerriero S, Angiolucci M, Lello S, Paoletti AM. Pharmacokinetic evaluation of ulipristal acetate for uterine leiomyoma treatment. Expert Opin Drug Metab Toxicol 2012; 8:901-8. [DOI: 10.1517/17425255.2012.695775] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mansour D, Verhoeven C, Sommer W, Weisberg E, Taneepanichskul S, Melis GB, Sundström-Poromaa I, Korver T. Efficacy and tolerability of a monophasic combined oral contraceptive containing nomegestrol acetate and 17β-oestradiol in a 24/4 regimen, in comparison to an oral contraceptive containing ethinylestradiol and drospirenone in a 21/7 regimen. EUR J CONTRACEP REPR 2011; 16:430-43. [PMID: 21995590 PMCID: PMC3233274 DOI: 10.3109/13625187.2011.614029] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The primary objective was to assess the efficacy, cycle control and tolerability of a monophasic combined oral contraceptive (COC) containing nomegestrol acetate (NOMAC) and 17β-oestradiol (E2). Effects on acne were evaluated as a secondary objective. Results were compared to those of a COC containing drospirenone (DRSP) and ethinylestradiol (EE). METHODS Women (aged 18-50 years) were randomised to receive NOMAC/E2 (2.5 mg/1.5 mg) in a 24/4-day regimen (n=1591) or DRSP/EE (3 mg/30 μg) in a 21/7-day regimen (n=535) for 13 cycles. RESULTS Estimated Pearl Indices for NOMAC/E2 and DRSP/EE were 0.38 and 0.81 in women aged≤35 years and 0.31 and 0.66 for all women (18-50 years), respectively. Scheduled withdrawal bleedings were shorter and lighter among users of NOMAC/E2 and were sometimes absent altogether. Intracyclic bleeding/spotting was infrequent in both groups, and decreased over time. Type and frequency of adverse events were similar to those typically reported for COCs. CONCLUSIONS These data show that NOMAC/E2 provides high contraceptive efficacy with acceptable cycle control as well as an overall adverse event profile similar to that of DRSP/EE.
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Affiliation(s)
- Diana Mansour
- Sexual Health Services, Newcastle Hospitals Community Health, Newcastle upon Tyne, UK.
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Angioni S, Sanna S, Magnini R, Melis GB, Fulghesu AM. The quantitative insulin sensitivity check index is not able to detect early metabolic alterations in young patients with polycystic ovarian syndrome. Gynecol Endocrinol 2011; 27:468-74. [PMID: 20540677 DOI: 10.3109/09513590.2010.492886] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To verify whether QUICKY is a suitable method for the identification of metabolic deterioration in normal weight patients affected by polycystic ovarian syndrome (PCOS). DESIGN Prospective clinical study. PATIENT(S) Seventy-nine PCOS normal weight adolescent subjects, 50 eumenorrheic, normal weight, non-hirsute controls matched for age and BMI. METHOD(S) Quantitative insulin sensitivity check index (QUICKY) and integrated secretory area under the curve of insulin values (I-AUC) during oral glucose tolerance test were calculated. RESULT(S) Seventy-nine PCOS and 50 controls were studied. Normal insulin sensitivity was defined as upper control 95th percentile by QUICKY values <0.31, I-AUC at 180 min < 16,645. When applying the calculated I-AUC cut-off, 41 PCOS were classified as normoinsulinemic and 38 as hyperinsulinemic, whereas using the calculated QUICKY cut-off, only 19 PCOS could be classified as insulin resistant (IR). Fifteen out of the 60 non-IR PCOS presented hyperinsulinemia; fasting glucose and insulin levels and QUICKY were not sufficient to identify these subjects. Thus, QUICKY displayed a low sensitivity (44%) and specificity (91%) in the diagnosis of the metabolic disorder disclosed by I-AUC. CONCLUSIONS.: In young normal weight patients with PCOS the prevalence of early alterations of insulin metabolism are not detectable by QUICKY studies.
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Affiliation(s)
- Stefano Angioni
- Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, Italy.
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Angioni S, Maricosu G, Mereu L, Mencaglia L, Melis GB. Single-port access laparoscopic assisted vaginal hysterectomy in a case of uterine ventrofixation using a new reusable device. J Obstet Gynaecol Res 2011; 37:933-6. [DOI: 10.1111/j.1447-0756.2010.01444.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Mais V, Angioli R, Coccia E, Fagotti A, Landi S, Melis GB, Pellicano M, Scambia G, Zupi E, Angioni S, Arena S, Corona R, Fanfani F, Nappi C. [Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]. Minerva Ginecol 2011; 63:47-70. [PMID: 21311420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.
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Affiliation(s)
- V Mais
- Divisione di Ginecologia, Ostetricia e Fisiopatologia della Riproduzione Umana, Dipartimento Chirurgico, Materno-Infantile e Scienze delle Immagini, Università di Cagliari, Ospedale San Giovanni di Dio, Cagliari, Italia.
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Guerriero S, Alcazar JL, Pascual MA, Ajossa S, Graupera B, Hereter L, Melis GB. The diagnosis of ovarian cancer: is color Doppler imaging reproducible and accurate in examiners with different degrees of experience? J Womens Health (Larchmt) 2011; 20:273-7. [PMID: 21265646 DOI: 10.1089/jwh.2010.2277] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To evaluate the reproducibility and accuracy of color Doppler flow location in indeterminate masses after a gray-scale sonography in the diagnosis of ovarian malignancy. METHODS Digitally stored color Doppler sonographic images from a random sample of 130 women with an indeterminate adnexal mass submitted to surgery were evaluated by six different examiners with different degrees of experience. A mass was graded malignant if flow was shown within the excrescences or solid areas. Intraobserver agreement and interobserver agreement according to the level of experience were assessed by calculating the kappa index. RESULTS Intraobserver agreement was good for all examiners with different degrees of experience (kappa 0.72-0.89). Interobserver agreement was good to moderate for all operators (kappa 0.48-0.71) irrespective of degree of experience. The accuracy was comparable among different operators. CONCLUSIONS Our results indicate that color Doppler imaging for detection of adnexal malignancy seems to be a reproducible method even in moderately experienced examiners.
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Affiliation(s)
- Stefano Guerriero
- San Giovanni di Dio Hospital, Department of Obstetrics and Gynaecology, University of Cagliari, Cagliari, Italy.
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Daemen A, Valentin L, Fruscio R, Van Holsbeke C, Melis GB, Guerriero S, Czekierdowski A, Jurkovic D, Ombelet W, Rossi A, Vergote I, Bourne T, De Moor B, Timmerman D. Improving the preoperative classification of adnexal masses as benign or malignant by second-stage tests. Ultrasound Obstet Gynecol 2011; 37:100-106. [PMID: 20814878 DOI: 10.1002/uog.8813] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE The aim of this study was to establish when a second-stage diagnostic test may be of value in cases where a primary diagnostic test has given an uncertain diagnosis of the benign or malignant nature of an adnexal mass. METHODS The diagnostic performance with regard to discrimination between benign and malignant adnexal masses for mathematical models including ultrasound variables and for subjective evaluation of ultrasound findings by an experienced ultrasound examiner was expressed as area under the receiver-operating characteristics curve (AUC), sensitivity and specificity. These were calculated for the total study population of 1938 patients with an adnexal mass as well as for subpopulations defined by the certainty with which the diagnosis of benignity or malignancy was made. The effect of applying a second-stage test to the tumors where risk estimation was uncertain was determined. RESULTS The best mathematical model (LR1) had an AUC of 0.95, sensitivity of 92% and specificity of 84% when applied to all tumors. When model LR1 was applied to the 10% of tumors in which the calculated risk fell closest to the risk cut-off of the model, the AUC was 0.59, sensitivity 90% and specificity 21%. A strategy where subjective evaluation was used to classify these 10% of tumors for which LR1 performed poorly and where LR1 was used in the other 90% of tumors resulted in a sensitivity of 91% and specificity of 90%. Applying subjective evaluation to all tumors yielded an AUC of 0.95, sensitivity of 90% and specificity of 93%. Sensitivity was 81% and specificity 47% for those patients where the ultrasound examiner was uncertain about the diagnosis (n = 115; 5.9%). No mathematical model performed better than did subjective evaluation among the 115 tumors where the ultrasound examiner was uncertain. CONCLUSION When model LR1 is used as a primary test for discriminating between benign and malignant adnexal masses, the use of subjective evaluation of ultrasound findings by an experienced examiner as a second-stage test in the 10% of cases for which the model yields a risk of malignancy closest to its risk cut-off will improve specificity without substantially decreasing sensitivity. However, none of the models tested proved suitable as a second-stage test in tumors where subjective evaluation yielded an uncertain result.
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Affiliation(s)
- A Daemen
- Department of Electrical Engineering ESAT/SCD, Katholieke Universiteit Leuven, Leuven, Belgium.
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Mais V, Cirronis MG, Piras B, Silvetti E, Cossu E, Melis GB. Intraoperative lymphatic mapping techniques for endometrial cancer. Expert Rev Anticancer Ther 2011; 11:83-93. [DOI: 10.1586/era.10.181] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
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Timmerman D, Ameye L, Fischerova D, Epstein E, Melis GB, Guerriero S, Van Holsbeke C, Savelli L, Fruscio R, Lissoni AA, Testa AC, Veldman J, Vergote I, Van Huffel S, Bourne T, Valentin L. Simple ultrasound rules to distinguish between benign and malignant adnexal masses before surgery: prospective validation by IOTA group. BMJ 2010; 341:c6839. [PMID: 21156740 PMCID: PMC3001703 DOI: 10.1136/bmj.c6839] [Citation(s) in RCA: 245] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To prospectively assess the diagnostic performance of simple ultrasound rules to predict benignity/malignancy in an adnexal mass and to test the performance of the risk of malignancy index, two logistic regression models, and subjective assessment of ultrasonic findings by an experienced ultrasound examiner in adnexal masses for which the simple rules yield an inconclusive result. DESIGN Prospective temporal and external validation of simple ultrasound rules to distinguish benign from malignant adnexal masses. The rules comprised five ultrasonic features (including shape, size, solidity, and results of colour Doppler examination) to predict a malignant tumour (M features) and five to predict a benign tumour (B features). If one or more M features were present in the absence of a B feature, the mass was classified as malignant. If one or more B features were present in the absence of an M feature, it was classified as benign. If both M features and B features were present, or if none of the features was present, the simple rules were inconclusive. SETTING 19 ultrasound centres in eight countries. PARTICIPANTS 1938 women with an adnexal mass examined with ultrasound by the principal investigator at each centre with a standardised research protocol. Reference standard Histological classification of the excised adnexal mass as benign or malignant. MAIN OUTCOME MEASURES Diagnostic sensitivity and specificity. RESULTS Of the 1938 patients with an adnexal mass, 1396 (72%) had benign tumours, 373 (19.2%) had primary invasive tumours, 111 (5.7%) had borderline malignant tumours, and 58 (3%) had metastatic tumours in the ovary. The simple rules yielded a conclusive result in 1501 (77%) masses, for which they resulted in a sensitivity of 92% (95% confidence interval 89% to 94%) and a specificity of 96% (94% to 97%). The corresponding sensitivity and specificity of subjective assessment were 91% (88% to 94%) and 96% (94% to 97%). In the 357 masses for which the simple rules yielded an inconclusive result and with available results of CA-125 measurements, the sensitivities were 89% (83% to 93%) for subjective assessment, 50% (42% to 58%) for the risk of malignancy index, 89% (83% to 93%) for logistic regression model 1, and 82% (75% to 87%) for logistic regression model 2; the corresponding specificities were 78% (72% to 83%), 84% (78% to 88%), 44% (38% to 51%), and 48% (42% to 55%). Use of the simple rules as a triage test and subjective assessment for those masses for which the simple rules yielded an inconclusive result gave a sensitivity of 91% (88% to 93%) and a specificity of 93% (91% to 94%), compared with a sensitivity of 90% (88% to 93%) and a specificity of 93% (91% to 94%) when subjective assessment was used in all masses. CONCLUSIONS The use of the simple rules has the potential to improve the management of women with adnexal masses. In adnexal masses for which the rules yielded an inconclusive result, subjective assessment of ultrasonic findings by an experienced ultrasound examiner was the most accurate diagnostic test; the risk of malignancy index and the two regression models were not useful.
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Affiliation(s)
- Dirk Timmerman
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, 3000 Leuven, Belgium.
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Lello S, Pacifico V, Primavera G, Guardianelli F, Sorge R, Paoletti AM, Melis GB, Raskovic D, Colonna L. [Short-term effect of an estroprogestin containing ethinylestradiol 20 mcg + drospirenone 3 mg in 24+4 regimen at hormonal and cutaneous level in ovarian hyperandrogenism]. Minerva Ginecol 2010; 62:509-513. [PMID: 21079572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
AIM evaluate the efficacy of an estroprogestin EP containing 20 mcg ethinilestradiol (EE) and 3 mg drospirenone (DRSP) in the treatment of hyperandrogenism. METHODS In this study, twenty hyperandrogenic patients were treated with an EP containing EE 20 mcg and DRSP 3 mg in 24+4 regimen for three months. Skin evaluation was performed both quantitatively and qualitatively. RESULTS AND CONCLUSION This EP combination showed, after a short-term treatment (three months) to decrease significantly seborrhea, acne, and circulating androgens (testosterone, deidroepiandrosterone sulphate, and androstenedione), while increased sex hormone binding globulin levels. Moreover, this EE 20 mcg/DRSP 3mg EP combination changed some parameters of skin quality, increasing corneometry (a parameter related to skin hydration), and reduced trans epidermal water loss (TEWL, a parameter related to skin evaporation), and erythema (a parameter related to skin inflammation). These results could be taken into account in individualizing the treatment of hyperandrogenic patients.
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Affiliation(s)
- S Lello
- Servizio di Ginecologia Endocrinologica e Fisiopatologia della Menopausa, IRCCS-Istituto Dermopatico dell'Immacolata, Rome, Italia.
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Meloni A, Antonelli A, Deiana S, Rocca A, Atzei A, Paoletti AM, Melis GB. Late preterm: obstetric management. J Matern Fetal Neonatal Med 2010; 23 Suppl 3:113-5. [DOI: 10.3109/14767058.2010.512137] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Van Holsbeke C, Van Belle V, Leone FPG, Guerriero S, Paladini D, Melis GB, Greggi S, Fischerova D, De Jonge E, Neven P, Bourne T, Valentin L, Van Huffel S, Timmerman D. Prospective external validation of the 'ovarian crescent sign' as a single ultrasound parameter to distinguish between benign and malignant adnexal pathology. Ultrasound Obstet Gynecol 2010; 36:81-87. [PMID: 20217895 DOI: 10.1002/uog.7625] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To determine the sensitivity and specificity of the 'ovarian crescent sign' (OCS)-a rim of normal ovarian tissue seen adjacent to an ipsilateral adnexal mass-as a sonographic feature to discriminate between benign and malignant adnexal masses. METHODS The patients included were a subgroup of patients participating in the International Ovarian Tumor Analysis (IOTA) Phase 2 study, which is an international multicenter study. The subgroup comprised 1938 patients, with an adnexal mass, recruited from 19 ultrasound centers in different countries. All patients were scanned using the same standardized ultrasound protocol. Information on more than 40 demographic and ultrasound variables were collected, but the evaluation of the OCS was optional. Only patients from centers that had evaluated the OCS in > or = 90% of their cases were included. The gold standard was the histological diagnosis of the adnexal mass. The ability of the OCS to discriminate between borderline or invasively malignant vs. benign adnexal masses, as well as between invasively malignant vs. other (benign and borderline) tumors, was determined and compared with the performance of subjective evaluation of ultrasound findings by the ultrasound examiner. RESULTS The OCS was evaluated in 1377 adnexal masses from 12 centers, 938 (68%) masses being benign, 86 (6%) borderline, 305 (22%) primary invasive and 48 (3%) metastases. The OCS was present in 398 (42%) of 938 benign masses, in 14 (16%) of 86 borderline tumors, in 18 (6%) of 305 primary invasive tumors (one malignant struma ovarii, one uterine clear cell adenocarcinoma and 16 epithelial carcinomas, i.e. four Stage I and 12 Stage II-IV) and in two (4%) of 48 ovarian metastases. Hence, the sensitivity and specificity for absent OCS to identify a malignancy was 92% and 42%, respectively, and the positive and negative likelihood ratios (LR+ and LR-, respectively) were 1.60 and 0.18. Subjective impression performed significantly better than the OCS. Sensitivity and specificity were 90% and 92%, respectively, LR+ was 11.0 and LR- was 0.10. For discrimination between invasive vs. benign or borderline tumors, the sensitivity for absent OCS was 94%, the specificity was 40%, the LR+ was 1.58 and the LR- was 0.14. CONCLUSION This study confirms previous reports that the presence of the OCS decreases the likelihood of invasive malignancy in adnexal masses. However it is a poor discriminator between benign and malignant adnexal masses.
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Affiliation(s)
- C Van Holsbeke
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.
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Guerriero S, Alcazar JL, Ajossa S, Galvan R, Laparte C, García-Manero M, Lopez-Garcia G, Melis GB. Transvaginal Color Doppler Imaging in the Detection of Ovarian Cancer in a Large Study Population. Int J Gynecol Cancer 2010; 20:781-6. [DOI: 10.1111/igc.0b013e3181de9481] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction:The aim of the study was to compare the diagnostic accuracy of grayscale sonography and that of color Doppler imaging in the diagnosis of ovarian malignancy in a prospective study by the Sardinia-Navarra group.Methods:The study was performed as a collaborative work at the 2 European university departments of obstetrics and gynecology between 1997 and 2007. A total of 2148 pelvic masses in 1997 women on whom transvaginal sonography were performed before surgical exploration were included in the study. An adnexal mass was first studied in grayscale sonography, and any cystic mass in which the echo architecture was not suggestive of benign tumor was categorized as malignant. Second, any solid excrescences or solid portions of the tumor were evaluated with color/power Doppler sonography. A mass was graded malignant if flow was shown within the excrescences or the solid areas and benign if there was no flow or if flow was only peripheral.Results:Four hundred sixty-eight masses were malignant. Color Doppler evaluation was more accurate in the diagnosis of adnexal malignancies in comparison with grayscale sonography because of a significantly higher specificity (94% vs 89%, P = 0.001), with similar sensitivity (95% vs 98%, P = 0.44). The pretest probability of ovarian cancer was 22%, and this probability rose to 82% when the diagnosis was suggested by color Doppler evaluation. The diagnostic accuracy of the tests was also dependent on menopausal status.Conclusions:The evaluation of vessel distribution by color Doppler sonography in adnexal masses increases the diagnostic accuracy of grayscale sonography in the detection of adnexal malignancies in a large study population.
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Fulghesu A, Magnini R, Portoghese E, Angioni S, Minerba L, Melis GB. Obesity-related lipid profile and altered insulin incretion in adolescents with polycystic ovary syndrome. J Adolesc Health 2010; 46:474-81. [PMID: 20413084 DOI: 10.1016/j.jadohealth.2009.10.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 10/20/2009] [Accepted: 10/22/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this study was evaluate influence of body mass index (BMI), hyperinsulinemia and/or insulin resistance (IR), and androgens on the lipid profile of adolescent polycystic ovary syndrome (PCOS). METHODS A total of 71 PCOS and 94 healthy adolescent girls from a Southern Italian region were included in the study. At day 5-8 of menstrual cycle, patients underwent a 75-g oral glucose tolerance test to evaluate insulin levels; lipid and homocysteine levels were also assessed, baseline hormonal assays and ultrasound examination performed, and anthropometric characteristics measured. RESULT No differences were observed in the incidence of overweight or obesity and total cholesterol, high-density lipoprotein (HDL) cholesterol level, low-density lipoprotein cholesterol level; triglycerides and homocysteine levels did not differ between PCOS and control groups. All fasting metabolic indexes were similar, whereas insulin secretion after glucose load (I-AUC) was significantly higher in PCOS subjects. Total cholesterol levels were significantly related to waist-hip ratio (WHR). Low-density lipoprotein level was positively correlated with BMI, waist, WHR, and homeostasis model assessment (HOMA) but not I-AUC. Findings obtained for HDL correlated negatively to the same parameters, being also negatively correlated to both fasting insulin and HOMA, but not I-AUC. Moreover, HDL was positively correlated to circulating androstenedione (A) and negatively to circulating testosterone (T) levels. Triglycerides seemed to correlate positively with body BMI, waist, and WHR, and negatively with A levels. Homocysteine levels correlated positively with plasma triglyceride content. CONCLUSION In the adolescent population studied, no differences were revealed in lipid profile between PCOS and controls. The PCOS is not a discriminant factor. The anthropometric characteristics resulted in the primary factor influencing the lipid derangement, confirming the importance of treating obesity at an early age to reduce morbidity rates. Hyperinsulinemia and IR, peculiarities of PCOS capable of influencing long-term evolution into cardiovascular diseases and diabetes mellitus, are not associated with worse lipid profile. Young patients should be encouraged and motivated to change their lifestyle, with the aim of losing weight and thus reducing risk of onset of overt dyslipidemia.
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Affiliation(s)
- Annamaria Fulghesu
- Department of Obstetrics and Gynecology, University of Cagliari, Via Ospedale Cagliari, Cagliari, Italy.
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Mais V, Peiretti M, Gargiulo T, Parodo G, Cirronis MG, Melis GB. Intraoperative sentinel lymph node detection by vital dye through laparoscopy or laparotomy in early endometrial cancer. J Surg Oncol 2010; 101:408-12. [PMID: 20119976 DOI: 10.1002/jso.21496] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent studies reported the feasibility of intraoperative lymphatic mapping in women with endometrial cancer but none of these studies compared the sentinel lymph nodes (SLNs) detection rates obtainable through laparoscopy or laparotomy. The purpose of this study was to address this issue. METHODS Thirty-four patients with clinical stage I-II endometrial cancer were enrolled in this prospective comparative trial. Four milliliters of Patent Blue Violet were injected into the cervix after the induction of general anesthesia. The assessment of SLNs was done in 17 patients through laparoscopy and in 17 patients through laparotomy as first step of systematic pelvic lymphadenectomy. Both SLNs and non-SLNs were evaluated for micrometastases. RESULTS The SLNs detection rate was significantly higher (82%) for laparoscopy than for laparotomy (41%; P = 0.008). Pelvic lymph node metastases were present in 6 out of 34 patients (18%) but only 3 (50%) of these patients were correctly identified. CONCLUSIONS SLNs detection rate is significantly higher through laparoscopy than through laparotomy after vital dye pericervical injection but intraoperative vital dye pericervical injection is not reliable as part of standard care for predicting lymphatic spread in women with early stage endometrial cancer.
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Affiliation(s)
- Valerio Mais
- Division of Gynecology, Department of Surgery, Maternal-Fetal Medicine, and Imaging, University of Cagliari Medical School, Cagliari, Italy
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Mereu L, Angioni S, Melis GB, Mencaglia L. Single access laparoscopy for adnexal pathologies using a novel reusable port and curved instruments. Int J Gynaecol Obstet 2010; 109:78-80. [PMID: 20070967 DOI: 10.1016/j.ijgo.2009.11.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 11/20/2009] [Accepted: 12/07/2009] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To present our initial experience using single access laparoscopic surgery for the treatment of benign adnexal pathologies. METHODS Sixteen patients with benign adnexal pathologies underwent salpingoophorectomy (n=9), ovarian cyst enucleation (n=5), or salpingectomy (n=2) using a laparoendoscopic single site approach with a new multiport reusable trocar and flexible and curved-as well as standard-laparoscopic instruments. RESULTS Conversion to a multi-access standard laparoscopic technique was not required in any patient and no intraoperative complications were observed. Postoperatively, one umbilical scar infection was detected. Mean operative time was 42 minutes. CONCLUSION Laparoscopic single site enucleation for adnexal pathologies is feasible, safe, and effective, and has good results for cosmetic appearance and postoperative pain. Use of specialized instruments and standardization of the technique affect surgical ergonomy and operating time.
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Affiliation(s)
- Liliana Mereu
- Division of Gynecology, Villanova Hospital of Firenze, Florence, Italy.
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Abstract
We describe the main issues encountered in pregnancy care in two perinatally infected adolescents with HIV. Despite the young maternal age, both mothers complied well with visits and treatment during pregnancy and delivered at week 38 through elective caesarean section. Both, however, missed the regular gynaecological and the routine HIV visits scheduled after pregnancy. Both infants following HIV exposure were confirmed HIV-negative at the end of tests performed in the first year of life. A growing number of similar cases is expected as perinatally infected children enter adolescence and become sexually active. These two cases indicate the feasibility of an adequate pregnancy care in very young HIV-positive women, but suggest that potential difficulties may be encountered in this population in maintaining optimal care after delivery. Such objectives might be better obtained with a timely transition of adolescents with HIV from paediatric clinics to a multiservice care setting which includes infectious diseases clinics, obstetric and gynaecologic departments and, particularly, counselling and educational services.
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Affiliation(s)
- Alessandra Meloni
- Department of Gynaecology and Obstetrics, S. Giovanni di Dio Hospital, University of Cagliari, Cagliari, CA, Italy.
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