Perioperative pain management after scapular tip free flap harvesting for head and neck reconstruction using mini-catheters to inject the local anesthetic

PURPOSE

Although functional and esthetic results after the use of a scapular tip free flap (STFF) in head and neck reconstruction, and the related donor-site morbidity, have been extensively described, data regarding acute postoperative donor-site pain management are lacking. Purpose of this study is to explore the use of mini-catheters to administer local anesthetics for donor-site pain management after reconstruction using STFF.

METHODS

Patients who underwent head and neck reconstruction using a STFF were prospectively enrolled and, through a perineural catheter placed in the donor site during the surgical procedure, a bolus of chirochaine was injected before the patient regained consciousness and at 8, 16, and 24 h postoperatively. Before and 40 min after each dose administration, donor-site pain on a numerical rating scale (NRS; 0-10) was evaluated.

RESULTS

Study population consisted of 20 patients (40-88 years). At 8 h, the pain scores before and after the injection were 0-10 (mean 3.35) and 0-5 (mean 1.25), respectively. At 16 h, the pain scores before and after the injection were 0-8 (mean 2.55) and 0-4 (mean 0.55), respectively. At 24 h, the pain scores before and after the injection were 0-8 (mean 1.30) and 0-4 (mean 0.30), respectively.

CONCLUSION

Statistical analysis confirmed a significant difference between the pain scores before and after administration at 8, 16, and 24 h (p < 0.001, p < 0.001, and p = 0.003, respectively). Mini-catheters for local anesthetic administration represent an effective strategy for pain control after STFF harvesting for head and neck reconstruction.

Idiopathic erythrocytosis: a germline disease?

Polycythemia Vera (PV) is typically caused by V617F or exon 12 JAK2 mutations. Little is known about Polycythemia cases where no JAK2 variants can be detected, and no other causes identified. This condition is defined as idiopathic erythrocytosis (IE). We evaluated clinical-laboratory parameters of a cohort of 56 IE patients and we determined their molecular profile at diagnosis with paired blood/buccal-DNA exome-sequencing coupled with a high-depth targeted OncoPanel to identify a possible underling germline or somatic cause. We demonstrated that most of our cohort (40/56: 71.4%) showed no evidence of clonal hematopoiesis, suggesting that IE is, in large part, a germline disorder. We identified 20 low mutation burden somatic variants (Variant allelic fraction, VAF, < 10%) in only 14 (25%) patients, principally involving DNMT3A and TET2. Only 2 patients presented high mutation burden somatic variants, involving DNMT3A, TET2, ASXL1 and WT1. We identified recurrent germline variants in 42 (75%) patients occurring mainly in JAK/STAT, Hypoxia and Iron metabolism pathways, among them: JAK3-V722I and HIF1A-P582S; a high fraction of patients (48.2%) resulted also mutated in homeostatic iron regulatory gene HFE-H63D or C282Y. By generating cellular models, we showed that JAK3-V722I causes activation of the JAK-STAT5 axis and upregulation of EPAS1/HIF2A, while HIF1A-P582S causes suppression of hepcidin mRNA synthesis, suggesting a major role for these variants in the onset of IE.

Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX

A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX.

INTRODUCTION

The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD).

METHODS

We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted β-coefficients.

RESULTS

A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72-2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69-2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63-2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62-2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination.

CONCLUSION

A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.

Thoughts and concerns of patients at hospital discharge after lumbar spine surgery. A qualitative study

PURPOSE

The increased rate of surgical interventions point to the necessity to investigate the patient's experience from a biopsychosocial perspective. The aim of this study was to investigate the thoughts and concerns of patients undergoing spinal surgery for lumbar degenerative disease at the time of their discharge from hospital.

METHODS

Semi-structured interviews were conducted with 28 patients. The questions investigated possible concerns associated to discharging them home. A content analysis was performed by a multidisciplinary group to identify the main themes that emerged from the interviews.

RESULTS

The patients were satisfied with the surgeons' preoperative explanations and description of expected prognosis. However, they were disappointed with the lack of information at hospital discharge, in particular regarding practical and behavioral recommendations. The patients expressed clear concerns about being left alone to deal with possible complications or difficulties they may encounter when returning home.

CONCLUSION

This study underlined the patients' need for a comprehensive psychological guidance and possibly a person of reference during the post-operative process. Discussing discharge with the patient was emphasized as an important issue to improve patients' compliance to the recovery process itself. Putting these elements into practice should help spine surgeons to manage better hospital discharge.IMPLICATIONS FOR REHABILITATIONA comprehensive discussion with the patient at the time of hospital discharge is clearly stressed as an important issue to improve patients' adherence to the recovery process.The patients complained of a lack of information when returning home, in particular regarding practical and behavioral recommendations.The patients expressed clear concerns about possible complications or difficulties they may encounter when returning home and they expressed their need to know whom they can contact for help if needed.A better understanding of the thoughts and concerns of patients undergoing spinal surgery at the time of their discharge from hospital should help spine surgeons to improve the management of hospital discharge and the post-operative recovery.

Air change rates and infection risk in school environments: Monitoring naturally ventilated classrooms in a northern Italian urban context

The importance of building ventilation in avoiding long-distance airborne transmission has been highlighted with the advent of the COVID-19 pandemics. Among others, school environments, in particular classrooms, present criticalities in the implementation of ventilation strategies and their impact on indoor air quality and risk of contagion. In this work, three naturally ventilated school buildings located in northern Italy have undergone monitoring at the end of the heating season. Environmental parameters, such as CO2 concentration and indoor/outdoor air temperature, have been recorded together with the window opening configurations to develop a two-fold analysis: i) the estimation of real air change rates through the transient mass balance equation method, and ii) the individual infection risk via the Wells-Riley equation. A strong statistical correlation has been found between the air change rates and the windows opening configuration by means of a window-to-volume ratio between the total opening area and the volume of the classroom, which has been used to estimate the individual infection risk. Results show that the European Standard recommendation for air renewal could be achieved by a window opening area of at least 1.5 m2, in the most prevailing Italian classrooms. Furthermore, scenarios in which the infector agent is a teacher show higher individual infection risk than those in which the infector is a student. In addition, the outcomes serve school staff as a reference to ensure adequate ventilation in classrooms and keep the risk of infection under control based on the number of the students and the volume of the classroom.

Serum neurofilament levels correlate with electrodiagnostic evidence of axonal loss in paclitaxel-induced peripheral neurotoxicity

INTRODUCTION

Paclitaxel-induced peripheral neurotoxicity (PIPN) typically manifests as a predominantly sensory axonopathy. Nerve conduction studies (NCS) represent the gold standard method to quantify axonal impairment in PIPN. Serum neurofilament light chain (sNfL) levels are emerging biomarkers for quantifying axonal damage in peripheral neuropathies. To date, the association between NCS abnormalities and sNfL levels during paclitaxel-based chemotherapy has not been specifically addressed.

METHODS

We prospectively conducted longitudinal measurement of sNfL levels in 27 chemotherapy-naïve breast cancer patients and correlated conventional NCS recordings with sNfL in 22 of them, before (T0) and after (T1) 12 cycles of weekly paclitaxel-based therapy.

RESULTS

PIPN was diagnosed in 24/27 patients (88%) after completion of the 12-week paclitaxel-based chemotherapy regimen. Serum NfL levels (pg/mL) were significantly higher at T1 compared to T0 (T0: 18.50 ± 12.88 vs T1: 255.80 ± 194.16; p < 0.001). The increase of sNfL levels at T1 significantly correlated with the decrease or abolishment of amplitudes recorded from the sural nerve (r = 0.620; p = 0.0035), sensory radial (r = 0.613; p = 0.005), sensory ulnar (r = 0.630; p = 0.005), and peroneal motor (r = 0.568; p = 0.024) nerves.

CONCLUSION

sNfL levels proportionally increase during chemotherapy administration and significantly correlate with NCS axonal abnormalities in patients with PIPN. A multimodal testing approach employing both sNfL and NCS might improve the PIPN diagnostic accuracy.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures.

INTRODUCTION

The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors.

METHODS

A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible.

RESULTS

Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed.

CONCLUSIONS

These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

P14.02.A Serum neurofilaments correlate with axonal loss in paclitaxel-induced peripheral neurotoxicity

Background

Paclitaxel-induced peripheral neuropathy (PIPN) is a dose-limiting axonal polyneuropathy. Nerve conduction studies (NCS) are unique for the assessment of axonal impairment in PIPN. Neurofilaments (NFs), constituent of the neuronal cytoskeleton, are emerging as axonal damage biomarker. To date, the association between changes in NCS and NfL quantification across paclitaxel treatment in breast cancer patients has not been specifically addressed.

MATERIAL AND METHODS: Prospective longitudinal measurement of sNfL levels and NCS in 27 chemotherapy-naïve breast cancer patients before (V0) and after completion (V1) of 12 cycles of weekly paclitaxel-based therapy.

Results

Serum NfL levels (in pg/mL) increased over the course of treatment in the whole of patients (T0: 18,509 +/- 12,886 vs T1:255,805 +/- 194,165, p&lt;0.001). The increase in sNfL levels at T1 showed a significant moderate correlation with the percentage of decrease in the amplitude of the sural (ρ = 0.6205 (p=0.0035), radial (r=0.6134, p=0.005)), ulnar (ρ = 0.6298 (p=0.005)) and peroneal motor (ρ = 0.5676, p=0.024)) nerve in NCS across treatment.

Conclusion

sNfL levels increase proportionally to the degree of paclitaxel-induced neuroaxonal damage, revealing being a promising blood biomarker able to detect the severity of large nerve fiber degeneration and, therefore, improving the diagnostic accuracy in PIPN.

Ventilation strategies to reduce airborne transmission of viruses in classrooms: A systematic review of scientific literature

The recent pandemic due to SARS-CoV-2 has brought to light the need for strategies to mitigate contagion between human beings. Apart from hygiene measures and social distancing, air ventilation highly prevents airborne transmission within enclosed spaces. Among others, educational environments become critical in strategic planning to control the spread of pathogens and viruses amongst the population, mainly in cold conditions. In the event of a virus outbreak - such as COVID or influenza - many school classrooms still lack the means to guarantee secure and healthy environments. The present review examines school contexts that implement air ventilation strategies to reduce the risk of contagion between students. The analysed articles present past experiences that use either natural or mechanical systems assessed through mathematical models, numerical models, or full-scale experiments. For naturally ventilated classrooms, the studies highlight the importance of the architectural design of educational spaces and propose strategies for aeration control such as CO₂-based control and risk-infection control. When it comes to implementing mechanical ventilation in classrooms, different systems with different airflow patterns are assessed based on their ability to remove airborne pathogens considering parameters like the age of air and the generation of airflow streamlines. Moreover, studies report that programmed mechanical ventilation systems can reduce risk-infection during pandemic events. In addition to providing a systematic picture of scientific studies in the field, the findings of this review can be a valuable reference for school administrators and policymakers to implement the best strategies in their classroom settings towards reducing infection risks.

O-192 Concomitant autoimmunity in endometriosis-affected women and In Vitro Fertilization (IVF) outcomes: a cohort study

Study question

To evaluate whether the presence of concomitant autoimmunity in endometriosis patients may affect In Vitro Fertilization (IVF)/Intracytoplasmic Injection (ICSI) outcomes.

Summary answer

In ‘normo-responders’ patients autoimmunity did not affected ovarian response to gonadotrophin stimulation yet was the only significant negative predictor of cumulative pregnancy rate (CPR).

What is known already

In the last years, endometriosis has been redefined as a multifactorial disease with a complex pathogenesis. In this setting, a role of both innate and adaptive immune systems have been proposed in endometriosis development. The coexistence of endometriosis and autoimmunity is well-documented. Also, an increased risk of more severe stages of endometriosis in patients with autoimmunity has been recently reported. Even if autoimmunity has been associated with lower pregnancy rates and higher miscarriage rates, whether the presence of autoimmunity in endometriosis patients could act as an additive factor worsening IVF/ICSI response is still not known.

Study design, size, duration

Single-center, retrospective, cohort study. First IVF/ICSI cycles of endometriosis patients with or without autoimmunity carried out from 2007 to 2021 at the Fertility Unit of IRCSS San Raffaele Hospital(Milan) were included. Patients with endometriosis and concomitant autoimmunity were age-matched to endometriosis only controls. Only patients with a complete disease control following endometriosis treatment were admitted to IVF/ICSI. A total of 471 patients were enrolled. The study was conducted according to STROBE guidelines for observational studies.

Participants/materials, setting, methods

Endometriosis diagnosis was surgical/histopathological, yet also ovarian endometriosis at ultrasound assessment by expert operators was included. Autoimmunity was assessed by blood tests for auto-antibodies and/or rheumatological records. Stratified analysis by “expected” ovarian response at baseline according to AFC and/or AMH were performed. Expected ‘poor-responders’ were defined according to Bologna Criteria. The primary outcome was CPR. Secondary outcomes included oocytes retrieved, metaphase II(MII)oocytes and ovarian sensitivity index(OSI), the latter defined as:(number of retrieved oocytes/total gonadotrophin dose)×1000.

Main results and the role of chance

113/471 cases with endometriosis and concomitant autoimmunity and 358/471 age-matched endometriosis only controls were enrolled. The mean age was 35.70±3.75 and 35.95±3.72 (p = 0.543) in cases and controls respectively. No baseline differences in endometriosis disease stage (p = 0.414), surgical treatment for endometriosis prior to IVF (p = 0.617), BMI (p = 0.866) or type of infertility (p = 0.255) were observed when comparing the two groups. In “expected normo-responders”, cases with autoimmunity had significantly higher numbers of oocytes retrieved (p = 0.007), MII oocytes (p = 0.007) and OSI index (p = 0.013) when compared to controls with endometriosis only; the CPR was 12.5% in cases vs. 17.5% in controls, thus comparable between the two groups (p = 0.143). In “expected poor-responders” no significant differences were observed neither in the number of oocytes retrieved and MII oocytes, nor in OSI index; the CPR was 12% in cases with concomitant autoimmunity compared to 7.75% in controls with endometriosis only (p = 0.256). In the generalized linear models (GLMs) of independent predictors associated with CPR, in expected ‘normo-responders’ autoimmunity was the only significant negative predictor of CPR (p = 0.004) whereas in ‘poor-responders’ only age negatively affected CPR (p = 0.001).

Limitations, reasons for caution

This study has a retrospective design. The interpretation of results is based on the validated yet still debated definition of poor-responders according to Bologna Criteria. Results should be interpreted with caution until replicated by future research providing multi-centric and prospective design, larger sample size and more standardized data collection.

Wider implications of the findings

Autoimmunity does not seem to impact neither ovarian reserve nor ovarian response to gonadotropin, as it may act a ‘competitive’ rather than ‘additive’ risk factor for infertility in endometriosis. However, in ‘normo-responders’ autoimmunity seems to reduce the chances of pregnancy following IVF/ICSI perhaps impairing endometrial receptivity and embryo implantation.

Trial registration number

Due to the retrospective design of the study, full IRB approval at the institution was not needed.

Diagnosis and management of osteoporosis in chronic kidney disease stages 4 to 5D: a call for a shift from nihilism to pragmatism

The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) CKD-MBD working group, in collaboration with the Committee of Scientific Advisors of the International Osteoporosis Foundation, published a position paper for the diagnosis and management of osteoporosis in patients with CKD stages 4-5D (eGFR < 30 ml/min 1.73 m²). The present article reports and summarizes the main recommendations included in this 2021 document. The following areas are reviewed: diagnosis of osteoporosis; risk factors for fragility fractures; fracture risk assessment; intervention thresholds for pharmacological intervention; general and pharmacological management of osteoporosis; monitoring of treatment, and systems of care, all in patients with CKD stages 4-5D. Guidance is provided for clinicians caring for CKD stages 4-5D patients with osteoporosis, allowing for a pragmatic individualized diagnostic and therapeutic approach as an alternative to current variations in care and treatment nihilism.

Higher serum levels of a cathepsin K-generated periostin fragment are associated with fractures in postmenopausal women with primary hyperparathyroidism: a pilot study

The only difference between fractured and non-fractured postmenopausal women with PHPT of same sex, age, and BMI was a significantly mean higher serum k-periostin level. K-periostin value was associated with fracture at any site (odds ratio 1.044, 95% CI 1.005-1.091, p = 0.03).

INTRODUCTION

To assess serum k-periostin fragment levels in patients with primary hyperparathyroidism (PHPT), fractured and non-fractured matched for sex, age, and body mass index.

METHODS

Twenty-five Caucasian fractured postmenopausal women with PHPT (group Fx) and 25 PHPT non-fractured (group NFx) were enrolled. Each patient underwent DXA scan at lumbar, hip, and forearm, spine X-ray, and biochemical evaluation of calcium metabolism. For k-periostin analyses, we utilized a specific ELISA test that detects CatK-generated fragment levels in the bloodstream.

RESULTS

We found no difference in mean BMD and bone turnover marker values between Fx and NFx groups. Prevalence of osteoporosis was not significantly different in Fx vs NFx (72% vs 60%, p = 0.55). Among Fx, 16% reported multiple fractures, 28% morphometric vertebral fractures, 4% femoral fractures, 28% non-vertebral non-femoral fractures, and 8% wrist fractures. The only detectable difference between Fx and NFx group was a significantly mean higher k-periostin serum level (46.2 ± 21.4 vs 34.7 ± 13.5 ng/ml, p = 0.02). K-periostin was associated with fracture at any site (odds ratio 1.044, 95% CI 1.005-1.091, p = 0.03). No difference in mean k-periostin values was found between patients with vertebral fracture vs those with non-vertebral fracture, and between those with multiple fractures vs those with single fracture.

CONCLUSION

Serum k-periostin is significantly associated with fracture in PHPT. If confirmed by further studies, k-periostin could be considered a new marker of bone fragility in PHPT, independently of BMD.

Pathophysiology of aniridia-associated keratopathy: Developmental aspects and unanswered questions

Aniridia, a rare congenital disease, is often characterized by a progressive, pronounced limbal insufficiency and ocular surface pathology termed aniridia-associated keratopathy (AAK). Due to the characteristics of AAK and its bilateral nature, clinical management is challenging and complicated by the multiple coexisting ocular and systemic morbidities in aniridia. Although it is primarily assumed that AAK originates from a congenital limbal stem cell deficiency, in recent years AAK and its pathogenesis has been questioned in the light of new evidence and a refined understanding of ocular development and the biology of limbal stem cells (LSCs) and their niche. Here, by consolidating and comparing the latest clinical and preclinical evidence, we discuss key unanswered questions regarding ocular developmental aspects crucial to AAK. We also highlight hypotheses on the potential role of LSCs and the ocular surface microenvironment in AAK. The insights thus gained lead to a greater appreciation for the role of developmental and cellular processes in the emergence of AAK. They also highlight areas for future research to enable a deeper understanding of aniridia, and thereby the potential to develop new treatments for this rare but blinding ocular surface disease.

P–349 Does concomitant autoimmunity affect IVF/ICSI outcomes in women with endometriosis? A retrospective observational study

Study question

To investigate differences in In Vitro Fertilization (IVF)/Intracytoplasmic Sperm Injection (ICSI) outcomes between endometriosis women who do or don’t have a concomitant autoimmune disease.

Summary answer

Despite a higher oocyte yield, a trend for reduction in clinical pregnancy rates was observed in the autoimmunity group compared to women without concomitant autoimmunity.

What is known already

Endometriosis is an inflammatory chronic gynaecological disorder with a known detrimental impact on fertility. Endometriosis pathogenesis is still unclear. It has been postulated a role of both innate and adaptive immune system. The coexistence of endometriosis and autoimmunity is a well-documented occurrence Some recent findings have revealed an increased risk to have concomitant autoimmune disease in women with endometriosis, but no study has so far investigated whether this association could affect IVF/ICSI outcomes. Indeed, autoimmune phenomena, including proinflammatory cytokines and auto-antibody production, may result in diminished quality of oocytes/embryos with lower pregnancy rates among these patients.

Study design, size, duration

This was a retrospective observational study carried out at the Fertility Unit of IRCSS San Raffaele Hospital (Milan). We reviewed medical patients’ notes of women with a confirmed diagnosis of endometriosis who referred to our Fertility Unit from October 2018 to January 2021.

Participants/materials, setting, methods

Out of 1441 patients undergoing IVF/ICSI, 98 women had surgical/histopathological diagnosis of endometriosis. 25 of them had a clinical and/or serological diagnosis of autoimmunity. Autoimmunity was assessed by clinical data (blood tests for auto-antibodies or rheumatological records) obtained from the electronic patient files stored in the database of our Fertility Centre. Clinical pregnancy was defined as the presence of at least one intrauterine gestational sac with a viable embryo at week 6 after transfer.

Main results and the role of chance

25/98 (25.5%) endometriosis women with a concomitant autoimmune disease (cases) were compared with 73/98 (74.5%) endometriosis patients without autoimmunity (controls). The mean age was 37.36±3.63 and 36.93±3.79 (p=.623) in cases and controls respectively. The mean number of oocytes retrieved was higher in cases (5.78±4.07) than in controls (3.82±2.69;p=.041); similarly, cases showed an higher number of embryos (2.13±1.93 vs. 1.19±1.37;p=.041) and blastocysts (1.89±2.02 vs. 0.85±1.61;p=.041) obtained. A total of 47 fresh embryo transfer (ET) were performed. Considering all the endometriosis patients, the clinical pregnancy rate (CPR) per cycle was 34.0% (16/47); when stratifying for the presence of autoimmunity the CPR was 23.1% (3/13) in cases, and 38.2% (13/34) in controls (p=.494).

Limitations, reasons for caution

This is a retrospective study based on data extraction from electronic records of our Fertility Centre. The sample size is limited and some information about past medical history could be missed. Results should be interpreted with caution until validated by future research providing more standardized data collection.

Wider implications of the findings: Despite significantly higher numbers of oocytes retrieved and embryos/blastocysts formed, the presence of concomitant autoimmune disease in patients with endometriosis may impair pregnancy rates. Whether this finding is confirmed and whether it could be due to a defect in embryo/blastocysts quality or in endometrial receptivity deserves further studies.

Trial registration number

Not applicable

Feasibility and effectiveness of interpersonal psychotherapy interventions in a collaborative stepped care model between primary care and mental health services

Introduction

The NICE guidelines recommend for mild major depression a range of low-intensity psychosocial intervention of proven effectiveness, as Interpersonal Counselling, and a stepped-care approach.

Objectives

To assess feasibility and effectiveness of Interpersonal Psychotherapy interventions for the treatment of depression in a consolidated Collaborative Stepped Care Model between primary care and mental health specialists.

Methods

103 patients were referred by their PCPs to the Consultation-Liaison Service of Bologna and Modena. Of them, 78 were included in the study and administered self-report instruments and interview, including screening depression, anxiety and daily functioning. Patients were asked to choose one of the available treatment: 1) Interpersonal Counseling (IPC) 6-8 weekly meetings for 30 minutes; 2) IPC for Depression in Primary Care 3 sessions of 50 minutes; 3) a guided self-help intervention. Follow-up were planned at 1, 3 and 6 months. Both patients and PCPs provided a feedback about intervention’s satisfactions.

Results

At the baseline, 39.4% of the patients presented a minor depression/major depression mild and the large majority (75.0%) of them chose IPC, while none of them chose the guided self-help intervention. At follow ups the mean PHQ-9 significantly decreased compared to the baseline (p<0.001); daily functioning increased (WSAS: p<0.001) and anxiety traits improved (STAI: p<0.001). Patient’s general satisfaction with the service received was high (GSQ: 85.9±15.0) as well as PCPs, 62.7% of them expressed high satisfaction for the intervention.

Conclusions

The study emphasised that IPC is an effective and feasible treatment very well suited to the primary care setting for an optimal management of depression.

Vertebral fracture: epidemiology, impact and use of DXA vertebral fracture assessment in fracture liaison services

Vertebral fractures are independent risk factors for vertebral and nonvertebral fractures. Since vertebral fractures are often missed, the relatively new introduction of vertebral fracture assessment (VFA) for imaging of the lateral spine during DXA-measurement of the spine and hips may contribute to detect vertebral fractures. We advocate performing a VFA in all patients with a recent fracture visiting a fracture liaison service (FLS). Fracture liaison services (FLS) are important service models for delivering secondary fracture prevention for older adults presenting with a fragility fracture. While commonly age, clinical risk factors (including fracture site and number of prior fracture) and BMD play a crucial role in determining fracture risk and indications for treatment with antiosteoporosis medications, prevalent vertebral fractures usually remain undetected. However, vertebral fractures are important independent risk factors for future vertebral and nonvertebral fractures. A development of the DXA technology, vertebral fracture assessment (VFA), allows for assessment of the lateral spine during the regular DXA bone mineral density measurement of the lumbar spine and hips. Recent approaches to the stratification of antiosteoporosis medication type according to baseline fracture risk, and differences by age in the indication for treatment by prior fracture mean that additional information from VFA may influence initiation and type of treatment. Furthermore, knowledge of baseline vertebral fractures allows reliable definition of incident vertebral fracture events during treatment, which may modify the approach to therapy. In this manuscript, we will discuss the epidemiology and clinical significance of vertebral fractures, the different methods of detecting vertebral fractures, and the rationale for, and implications of, use of VFA routinely in FLS. • Vertebral fracture assessment is a tool available on modern DXA instruments and has proven ability to detect vertebral fractures, the majority of which occur without a fall and without the signs and symptoms of an acute fracture. • Most osteoporosis guidelines internationally suggest that treatment with antiosteoporosis medications should be considered for older individuals (e.g., 65 years +) with a recent low trauma fracture without the need for DXA. • Younger individuals postfracture may be risk-assessed on the basis of FRAX® probability including DXA and associated treatment thresholds. • Future fracture risk is markedly influenced by both site, number, severity, and recency of prior fracture; awareness of baseline vertebral fractures facilitates definition of true incident vertebral fracture events occurring during antiosteoporosis treatment. • Detection of previously clinically silent vertebral fractures, defining site of prior fracture, might alter treatment decisions in younger or older FLS patients, consistent with recent IOF-ESCEO guidance on baseline-risk-stratified therapy, and provides a reliable baseline from which to define new, potentially therapy-altering, vertebral fracture events.

The underestimated burden of aspiration event and pneumonia within hospitals: what happens after dysphagia

Study design

Prospective observational study.

Background

Despite dysphagia large prevalence and the growing ageing phenomenon occurring in European countries, aspiration events among inpatients are often underestimated, given their frequent spontaneous resolution or silent contribution to aspiration syndromes. Our main objective was to evaluate the incidence of aspiration events among medical inpatients and to identify risk factors influencing the outcome of the event.

Methods

Data about aspiration events - day, hour, type and outcome of the event occurred - along with underlying patient clinical conditions at the admission were collected. Between May 2015 and September 2016, data about aspiration event occurred among medical inpatients were collected in three large Italian hospitals.

Results

Patients affected by aspiration events were 135 on 102,619 cumulative days of hospitalization; they were mostly females (53%) with an average age of 82. The total incidence of aspiration events was of 1.4 every 1,000 days of hospitalization (C.I. 95%: 1.2-1.7) and the most frequent manifestation was cough (61.6%). The addition of drugs or an infection diagnosis during the 24 hours preceding the event acted as risk factors for those events that needed additional interventions during the hospitalization (OR 3.1 e OR 1.9 respectively), while the elimination of one or more prescribed drugs seemed to lead to aspiration events without impact on the hospitalization.

Conclusions

Results showed a large incidence of aspiration events within medical wards, many of them influencing patient outcomes. Healthcare professionals' attention concerning aspiration events should be fostered during the first hours and days of hospitalization.

Bone fragility in patients affected by congenital diseases non skeletal in origin

BACKGROUND

Bone tissue represents a large systemic compartment of the human body, with an active metabolism, that controls mineral deposition and removal, and where several factors may play a role. For these reasons, several non-skeletal diseases may influence bone metabolism. It is of a crucial importance to classify these disorders in order to facilitate diagnosis and clinical management. This article reports a taxonomic classification of non-skeletal rare congenital disorders, which have an impact on bone metabolism METHODS: The International Osteoporosis Foundation (IOF) Skeletal Rare Diseases Working Group (SRD-WG), comprised of basic and clinical scientists, has decided to review the taxonomy of non-skeletal rare disorders that may alter bone physiology.

RESULTS

The taxonomy of non-skeletal rare congenital disorders which impact bone comprises a total of 6 groups of disorders that may influence the activity of bone cells or the characteristics of bone matrix.

CONCLUSIONS

This paper provides the first comprehensive taxonomy of non-skeletal rare congenital disorders with impact on bone physiology.

Clinical and Socio-demographic Variables Associated with the Outcome of Vocational Rehabilitation Programs: A Community-Based Italian Study

This study aims to identify clinical and socio-demographic variables associated with the outcome of vocational rehabilitation programs (VRPs). All users of an Italian Community Mental Health Centre (CMHC) included in VRPs delivered according to the model of Supported Employment in years 2011-2016 were retrospectively enrolled. Fifty users who ended the program with employment were compared with fifty users who dropped out, with respect to clinical and socio-demographic variables. VRPs lasting less than 6 months and oriented toward the competitive labor market had a higher probability of employment. Among users who successfully ended the VRP, the median of health interventions significantly decreased after employment. In the same group of users, less non-health interventions strictly linked to the VRP were required, when compared with users who dropped out. We conclude that employment is associated with improvement of users' clinical conditions and reduced workload for the CMHC.

A patient-level key performance indicator set to measure the effectiveness of fracture liaison services and guide quality improvement: a position paper of the IOF Capture the Fracture Working Group, National Osteoporosis Foundation and Fragility Fracture Network

The International Osteoporosis Foundation (IOF) Capture the Fracture® Campaign with the Fragility Fracture Network (FFN) and National Osteoporosis Foundation (NOF) has developed eleven patient-level key performance indicators (KPIs) for fracture liaison services (FLSs) to guide quality improvement.

INTRODUCTION

Fracture Liaison Services (FLSs) are recommended worldwide to reduce fracture risk after a sentinel fracture. Given not every FLS is automatically effective, the IOF Capture the Fracture working group has developed and implemented the Best Practice Framework to assess the organisational components of an FLS. We have now developed a complimentary KPI set that extends this assessment of performance to the patient level.

METHODS

The Capture the Fracture working group in collaboration with the Fragility Fracture Network Secondary Fragility Fracture Special Interest Group and National Osteoporosis Foundation adapted existing metrics from the UK-based Fracture Liaison Service Database Audit to develop a patient-level KPI set for FLSs.

RESULTS

Eleven KPIs were selected. The proportion of patients: with non-spinal fractures; with spine fractures (detected clinically and radiologically); assessed for fracture risk within 12 weeks of sentinel fracture; having DXA assessment within 12 weeks of sentinel fracture; having falls risk assessment; recommended anti-osteoporosis medication; commenced of strength and balance exercise intervention within 16 weeks of sentinel fracture; monitored within 16 weeks of sentinel fracture; started anti-osteoporosis medication within 16 weeks of sentinel fracture; prescribed anti-osteoporosis medication 52 weeks after sentinel fracture. The final KPI measures data completeness for each of the other KPIs. For these indicators, levels of achievement were set at the < 50%, 50-80% and > 80% levels except for treatment recommendation where a level of 50% was used.

CONCLUSION

This KPI set compliments the existing Best Practice Framework to support FLSs to examine their own performance using patient-level data. By using this KPI set for local quality improvement cycles, FLSs will be able to efficiently realise the full potential of secondary fracture prevention and improved clinical outcomes for their local populations.

Experiences, opinions and current policies on users' choice and change of the allocated primary mental health professional: a survey among directors of community mental health centers in the Emilia-Romagna region, Italy

Background

The subject of how the initial allocation of the primary mental health professional (PMHP) in community mental health services is made and the frequency and management of users’ requests to choose and/or change their allocated PMHPs has been scarcely investigated. The present paper is aimed at exploring the experiences and opinions of directors of community mental health centers (CMHC) on this topic.

Methods

A cross-sectional survey was conducted. Electronic ad hoc questionnaires with both multiple choice and open-ended questions were e-mailed to the institutional addresses of CMHC directors in the Emilia-Romagna Region (Northern Italy) with the consent of their heads of department and the Ethical Committee. Quantitative data were analysed by means of Microsoft Excel software and STATA 14.2 (College Station, TX), while the qualitative analysis was performed using the Nvivo12 software.

Results

Twenty-eight questionnaires were collected (response rate: 71.8%) that were equally distributed between males and females. For the initial PMHP allocation, casual allocation by “fixed-rota” was commonly performed (39.3%). Moreover, hope for a change of prescription by a different psychiatrist was the most frequent reason for users’ requests to change their PMHP. In two mental health departments only (Parma and Bologna), written guidelines to manage users’ requests of change of PMHP were available. In this context, most participants classified the explored topics as relevant and believed that written policies, especially if shared with users, could be useful.

Conclusions

In Emilia-Romagna CMHCs, neither users nor professionals were generally involved in the initial choice of the PMHP. Further national-level studies should be conducted in order to confirm this finding. Additionally, written and shared guidelines for managing users’ request to choose/change their PHMP may be useful.

The Traveller's Risk Perception (TRiP) questionnaire: pre-travel assessment and post-travel changes

BACKGROUND

Travellers' risk perception is a key component of travel risk assessment because it influences the adequate implementation of safety precautions. The aims of this study are to validate a tool to analyse travellers' risk perception to identify which factors can influence it and how it changes upon return.

METHODS

The Traveller's Risk Perception (TRiP) questionnaire was developed and administered to outpatients before and after travel in three travel clinics. A principal component analysis (PCA) was performed to validate the questionnaire and multivariate regression analysis was used to evaluate the effect of travellers' characteristics on the risk scores.

RESULTS

A total of 1020 travellers completed the questionnaire. PCA identified two latent factors: 'generic-disseminated risks' and 'specific-circumstantial risks'. Cronbach's α was acceptable (0.76 and 0.70, respectively). The 'generic-disseminated risks' dimension scored higher than the 'specific-circumstantial risks' (p<0.001). The items with the highest scores were insect bites, gastrointestinal disorders and malaria. The mean scores were significantly lower after the travel for all items but one.

CONCLUSIONS

The TRiP questionnaire is a valid and reliable tool for rating travellers' perceptions. Staff in travel clinics should be trained to systematically assess travellers' risk perception in order to tailor the consultation according to specific information needs.

What Does it take to Become a Psychiatrist? Results from a Survey on Quality of Training

As models of mental health care and the professional identity of psychiatry are dramatically changing throughout Europe, a constant redefinition of aims, procedures and standards of training in psychiatry is widely perceived as necessary. The aim of the present study was to assess, in a group of trainees in psychiatry and early career psychiatrists, facts and opinions about their own training.

A 30-item ad hoc structured questionnaire, with both yes/no questions and rating scales, was administered to 92 Italian trainees in psychiatry and young psychiatrists, during a training event. The questionnaire focused on general work-related aspects (job satisfaction, self-confidence in different skills and therapeutic interventions) but also on more specific training-related aspects (supervision, training in psychotherapy, methods of evaluations, training in research).

Mean (SD) age of respondents was 30 (3.51) years, with a M/F ratio of 0.31. Sixty-nine percent of respondents deemed themselves generally “satisfied” with their training, but when considering some specific areas of training, such as psychotherapy and forensic psychiatry, the satisfaction rates were sensibly lower (33 and 19% respectively). Lower levels of professional self-confidence were associated to forensic psychiatry, child and adolescent psychiatry, and emergency psychiatry. Respondents also reported problems in the definition and application of training instruments such as supervision and a training log-book.

The definition and implementation of minimum educational international standards for training in psychiatry is still necessary. Thus, continuous research on definition of educational standards in psychiatry has to be promoted throughout Europe.

Energy-level quantization and single-photon control of phase slips in YBa2Cu3O7-x nanowires

Significant progress has been made in superconducting quantum circuits. However new quantum devices that have longer decoherence times at higher temperatures are urgently required for quantum technologies. Superconducting nanowires with quantum phase slips are promising candidates for use in novel quantum devices. Here, we demonstrate YBa₂Cu₃O_7-x nanowires with phase-slip dynamics and study their switching-current statistics at temperatures below 20 K. We apply theoretical models developed for Josephson junctions and show that our results provide strong evidence for energy-level quantization in the nanowires. The crossover temperature to the quantum regime of 12-13 K and the lifetime in the excited state exceeding 20 ms at 5.4 K are superior to those in conventional Josephson junctions. We also show how the absorption of a single photon changes the phase-slip and quantum state of a nanowire, which is important for the development of single-photon detectors with high operating temperature and superior temporal resolution.

Subgroup comparison according to clinical phenotype and serostatus in autoimmune encephalitis: a multicenter retrospective study

BACKGROUND AND PURPOSE

Autoimmune encephalitides (AE) include a spectrum of neurological disorders whose diagnosis revolves around the detection of neuronal antibodies (Abs). Consensus-based diagnostic criteria (AE-DC) allow clinic-serological subgrouping of AE, with unclear prognostic implications. The impact of AE-DC on patients' management was studied, focusing on the subgroup of Ab-negative-AE.

METHODS

This was a retrospective multicenter study on patients fulfilling AE-DC. All patients underwent Ab testing with commercial cell-based assays (CBAs) and, when available, in-house assays (immunohistochemistry, live/fixed CBAs, neuronal cultures) that contributed to defining final categories. Patients were classified as Ab-positive-AE [N-methyl-d-aspartate-receptor encephalitis (NMDAR-E), Ab-positive limbic encephalitis (LE), definite-AE] or Ab-negative-AE (Ab-negative-LE, probable-AE, possible-AE).

RESULTS

Commercial CBAs detected neuronal Abs in 70/118 (59.3%) patients. Testing 37/48 Ab-negative cases, in-house assays identified Abs in 11 patients (29.7%). A hundred and eighteen patients fulfilled the AE-DC, 81 (68.6%) with Ab-positive-AE (Ab-positive-LE, 40; NMDAR-E, 32; definite-AE, nine) and 37 (31.4%) with Ab-negative-AE (Ab-negative-LE, 17; probable/possible-AE, 20). Clinical phenotypes were similar in Ab-positive-LE versus Ab-negative-LE. Twenty-four/118 (20.3%) patients had tumors, and 19/118 (16.1%) relapsed, regardless of being Ab-positive or Ab-negative. Ab-positive-AE patients were treated earlier than Ab-negative-AE patients (P = 0.045), responded more frequently to treatments (92.3% vs. 65.6%, P < 0.001) and received second-line therapies more often (33.3% vs. 10.8%, P = 0.01). Delays in first-line therapy initiation were associated with poor response (P = 0.022; odds ratio 1.02; confidence interval 1.00-1.04).

CONCLUSIONS

In-house diagnostics improved Ab detection allowing better patient management but was available in a patient subgroup only, implying possible Ab-positive-AE underestimation. Notwithstanding this limitation, our findings suggest that Ab-negative-AE and Ab-positive-AE patients share similar oncological profiles, warranting appropriate tumor screening. Ab-negative-AE patients risk worse responses due to delayed and less aggressive treatments.

Detection of Campylobacter spp. in water by dead-end ultrafiltration and application at farm level

AIMS

The purposes were to evaluate the detection of low levels of Campylobacter in water by dead-end ultrafiltration (DEUF) to determine the sensitivity and suitability for use under field condition.

METHODS AND RESULTS

The DEUF technique followed by detection according to ISO 10272 was tested on artificially and naturally contaminated water. Campylobacter were detected in all samples spiked with more than 10 CFU 60 l-1 and in four of nine samples with a concentration below 10 CFU 60 l-1 water. Naturally contaminated water from five different broiler producers was analysed. Campylobacter were detected in four of 12 samples from ponds near the houses and in three of 24 samples from water pipes inside the broiler houses, but not in tap water sampled at the entrance of the broiler houses.

CONCLUSIONS

The results indicate that DEUF is useful for detection of low numbers of Campylobacter in large volumes of water.

SIGNIFICANCE AND IMPACT OF THE STUDY

Contaminated water is an important source for transmission of Campylobacter to broilers and humans. The concentration of Campylobacter is usually low with a high level of background microbiota. This study shows the advantages of DEUF both in the laboratory and under field conditions.

Fracture risk following intermission of osteoporosis therapy

Given the widespread practice of recommending drug holidays, we reviewed the impact of medication discontinuation of two common anti-osteoporosis therapies (bisphosphonates and denosumab). Trial evidence suggests the risk of new clinical fractures, and vertebral fracture increases when osteoporosis treatment with bisphosphonates or denosumab is stopped.

INTRODUCTION

The aim of this paper was to review the available literature to assess what evidence exists to inform clinical decision-making with regard to drug holidays following treatment with bisphosphonates (BiP) or denosumab.

METHODS

Systematic review.

RESULTS

Differing pharmacokinetics lead to varying outcomes on stopping therapy. Prospective and retrospective analyses report that the risk of new clinical fractures was 20-40% higher in subjects who stopped BiP treatment, and vertebral fracture risk was approximately doubled. Rapid bone loss has been well described following denosumab discontinuation with an incidence of multiple vertebral fractures around 5%. Studies have not identified risk factors for fracture after stopping treatment other than those that provide an indication for treatment (e.g. prior fracture and low BMD). Studies that considered long-term continuation did not identify increased fracture risk, and reported only very low rates of adverse skeletal events such as atypical femoral fracture.

CONCLUSIONS

The view that patients on long-term treatment with bisphosphonates or denosumab should always be offered a drug holiday is not supported by the existing evidence. Different pharmacokinetic properties for different therapies require different strategies to manage drug intermission. In contrast, long-term treatment with anti-resorptives is not associated with increased risk of fragility fractures and skeletal adverse events remain rare.

Higher rates of osteoporosis treatment initiation and persistence in patients with newly diagnosed vertebral fracture when introduced in inpatients than later in outpatients

Whether in-hospital management of patients with newly identified vertebral fractures leads to a higher rate of osteoporosis medication than delayed outpatient management remains unknown. Our study showed that early osteoporosis therapy initiation in a fracture liaison service during hospital stay was a more efficacious strategy for secondary fracture prevention.

INTRODUCTION

Fracture liaison services are standard care for secondary fracture prevention. A higher rate of osteoporosis treatment initiation may be considered when introduced in the hospital rather than an outpatient recommendation to a primary care physician (PCP). Whether this applies to patients with newly detected vertebral fractures in a general internal medicine ward remains unknown. We prospectively investigated whether in-hospital management of newly identified vertebral fractures led to a higher rate of osteoporosis medication initiation and persistence at 3 and 6 months than delayed outpatient management by a PCP.

METHODS

We conducted a prospective study including hospitalized patients > 60 years systematically searched for asymptomatic vertebral fractures on lateral chest and/or abdominal radiographs. Patients were included either in phase 1 (outpatient care recommendations on osteoporosis management to a PCP) or in phase 2 (inpatient care management initiated during hospitalization). The percentage of patients under osteoporosis treatment was evaluated by telephone interview at 3 and 6 months.

RESULTS

Outpatients' (84 with fracture/407 assessed (21%); 75.7 ± 7.7 years) and inpatients' (100/524 (19%); 77.8 ± 9.4 years) characteristics were similar. Osteoporosis medication was more often prescribed in inpatients at 3 (67% vs. 19%, respectively; p < 0.001) and 6 months (69 vs. 27%, respectively; p < 0.001). The percentage under treatment was also higher in inpatients than in outpatients at 3 (52 vs. 19%, p < 0.001) and 6 months (54 vs. 22%, p < 0.001). Length of stay and destination post-discharge were not different between groups.

CONCLUSIONS

Early patient management after a newly detected vertebral fracture during hospitalization was a more efficacious strategy of secondary fracture prevention than delayed outpatient management following discharge.

Assessment of ovarian reserve after cystectomy versus 'one-step' laser vaporization in the treatment of ovarian endometrioma: a small randomized clinical trial

STUDY QUESTION

Does CO2 laser vaporization offer better results in treating endometrioma in terms of ovarian reserve preservation compared to traditional cystectomy?

SUMMARY ANSWER

Assessing both antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels as measures of ovarian reserve, the results suggest that CO2 technology may be an alternative treatment for endometrioma, causing minimal damage to adjacent healthy ovarian tissue.

WHAT IS KNOWN ALREADY

Excisional surgery has been questioned as an ideal surgical approach for endometriomas because it is associated with potential reduction of ovarian reserve. Recently, vaporization with CO2 laser in-line-of-sight, according to the 'three-step procedure', has been proposed as the best method to preserve ovarian function. However, no randomized controlled trials have been conducted to compare cystectomy and 'one-step' CO2 fiber laser vaporization (without GnRH agonist therapy) with respect to the ovarian reserve.

STUDY DESIGN, SIZE, DURATION

A multicentre randomized clinical trial including 60 patients was performed between July 2017 and February 2018. Computerized randomization was conducted to allocate them in a proportion of 1:1 either to Group 1 (laparoscopic stripping: cystectomy) or Group 2 (CO2 laser vaporization). Patients in Group 1 underwent a standardized laparoscopic stripping technique; patients in Group 2 underwent drainage of the cyst content, biopsy and vaporization of the internal wall with a CO2 fiber laser. Patients underwent pelvic ultrasound examination to determine the AFC and blood sampling to determine AMH levels before surgery and at 1- and 3-month follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients undergoing surgery for symptomatic endometriomas (infertility and/or pelvic pain) larger than 3 cm were randomized in two groups according to the surgical technique. Patients aged ≥40 years, or with deep infiltrating endometriosis/adenomyosis, or previously submitted to surgical procedures on the ovaries or to hysterectomy were excluded from the study. The primary endpoint was the comparison of intra-group AFC changes before and after surgery (ΔAFC) between the two groups (ΔAFC Group 1 versus ΔAFC Group 2). The secondary endpoint was the modification of serum AMH before and after surgery (ΔAMH) between the two groups (ΔAMH Group 1 versus ΔAMH Group 2).

MAIN RESULTS AND THE ROLE OF CHANCE

The AFC of the operated ovary was significantly increased in Group 2 (laser vaporization) compared with Group 1 (cystectomy) after surgery (Group 1: from 4.1 ± 2.2 [mean ± SD] at baseline to 6.3 ± 3.5 at 3-month follow-up; 95% CI: 0.9-4; Group 2: from 3.6 ± 1.9 at baseline to 8.6 ± 4.2 at 3-month follow-up; 95% CI: 2.8-7.1; P = 0.016); serum AMH levels were significantly reduced at 3 months in Group 1 (from 2.6 ± 1.4 ng/mL at baseline to 1.8 ± 0.8 ng/mL at 3-month follow-up; 95% CI: -1.3 to -0.2; P = 0.012) compared with no reduction in Group 2 (from 2.3 ± 1.1 ng/mL at baseline to 1.9 ± 0.9 ng/mL at 3-month follow-up; 95% CI: -1 to -0.2; P = 0.09).

LIMITATIONS, REASON FOR CAUTION

The key limitations of the trial were the low accuracy of AFC in estimating the ovarian reserve in ovaries with endometriomas, the limited study size and the relatively short follow-up, which do not allow us to draw definitive conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

The present study suggests that CO2 technology may treat endometrioma with minimal damage to the adjacent healthy ovarian tissue; however, this study should be considered as a preliminary clinical trial, intended to stimulate future larger trials to address this clinically relevant issue.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT03227640.

TRIAL REGISTRATION DATE

9 July 2017.

DATE OF FIRST PATIENT’S ENROLLMENT

24 July 2017.

Relationship Between Bone Mineral Density T-Score and Nonvertebral Fracture Risk Over 10 Years of Denosumab Treatment

Although treat-to-target strategies are being discussed in osteoporosis, there is little evidence of what the target should be to reduce fracture risk maximally. We investigated the relationship between total hip BMD T-score and the incidence of nonvertebral fracture in women who received up to 10 years of continued denosumab therapy in the FREEDOM (3 years) study and its long-term Extension (up to 7 years) study. We report the percentages of women who achieved a range of T-scores at the total hip or femoral neck over 10 years of denosumab treatment (1343 women completed 10 years of treatment). The incidence of nonvertebral fractures was lower with higher total hip T-score. This relationship plateaued at a T-score between -2.0 and -1.5 and was independent of age and prevalent vertebral fractures, similar to observations in treatment-naïve subjects. Reaching a specific T-score during denosumab treatment was dependent on the baseline T-score, with higher T-scores at baseline more likely to result in higher T-scores at each time point during the study. Our findings highlight the importance of follow-up BMD measurements in patients receiving denosumab therapy because BMD remains a robust indicator of fracture risk. These data support the notion of a specific T-score threshold as a practical target for therapy in osteoporosis. © 2019 The Authors Journal of Bone and Mineral Research published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research (ASBMR).

Diagnosis, prevention, and treatment of bone fragility in people living with HIV: a position statement from the Swiss Association against Osteoporosis

Life expectancy of people living with HIV (PLWH) is reaching similar length as in the general population. Accordingly, age-related comorbidities, including osteoporosis, are increasing. Fracture risk is higher and increases approximately 10 years earlier in PLWH. Classical risk factors of bone fragility are highly prevalent in PLWH but factors specific for HIV infection itself and the type of antiretroviral therapy (ART) (triple combination antiretroviral therapy) regimen (especially tenofovir and protease inhibitors) also contribute to bone loss. The majority of bone loss occurs during virus activity and at initiation of ART (immune reconstitution) and is associated with an increase of bone resorption (upregulation RANKL). Recent data indicate that calcium and vitamin D supplements as ART initiation lower BMD loss. The reduction of tenofovir plasma concentrations with tenofovir alafenamide attenuates BMD loss but it remains unknown whether it will contribute to reduce fracture risk. Hence, special considerations for the management of bone fragility in PLWH are warranted. Based on the current state of epidemiology and pathophysiology of osteoporosis in PLWH, we provide the consensus of the Swiss Association against Osteoporosis on best practice for diagnosis, prevention, and management of osteoporosis in this population. Periodic assessment of fracture risk is indicated in all HIV patients and general preventive measures should be implemented. All postmenopausal women, men above 50 years of age, and patients with other clinical risk for fragility fractures qualify for BMD measurement. An algorithm clarifies when treatment with bisphosphonates and review of ART regimen in favour of more bone-friendly options are indicated.

The Prevalence of patients with panic attacks (PAs) and panic disorder (PD) visiting Emergency Departments of the Verona Hospital

BACKGROUND

Panic Attacks (PAs) and Panic Disorder (PD) represent a heavy burden not only because of the difficulty in distinguishing them from other pathologies and in treating them appropriately but also because of their impact on public health worldwide. In Europe, PD constitutes one of the five most common mental disorders adversely affecting quality of life.

STUDY DESIGN

The aim of this study is to evaluate the period prevalence of visits to the Emergency Departments of the University Hospital of Verona (North East of Italy) over the period between 2012-2016 because of symptoms of PAs or PD in order to quantify the burden of the disorder.

METHODS

This study was carried out by retrospectively collecting data from the medical records of all the patients assessed at the Emergency Departments (EDs) of the Verona Hospital because of symptoms of PAs or PD over a 5-year period (1 January 2012 - 31 December 2016). The search words used in reviewing the medical records registered in the hospital discharge reports from the Gynecological, Pediatric and General Medicine Emergency Departments were: "Anxiety" and/or "Panic". A multiple logistic regression model was also created to evaluate the predictors of ED visits for PAs or PD over the period that was investigated.

RESULTS

The study identified 3,771 cases of PAs or PD; 62.3% were females and 37.7% were males. The female-to-male ratio was 1.7:1. The mean age was 44 years (46 for the females and 41 for the males). The majority of the patients fell into two age categories: 30 to 39 (20.6%) and 40 to 49 (23.8%). The proportion of visits to the EDs for PAs or PD was approximately 20% per year, with an average of approximately 754 patients visiting the EDs every year. The period prevalence of accesses for PAs or PD over the five year period studied in the mean resident population (1.4%) and the mean visits to the EDs (2.5%) were calculated. Study results showed that the majority of the patients (80.9%) were referred to their general practitioner (GP) at the end of the assessment protocol at the EDs. According to the regression logistic model, the following variables were significant (p<0.05) risk factors for PAs or PD: being female vs. male (OR 1.899; 95% CI 1.785-2.020), being Italian vs. Foreigner (OR 1.292; 95% CI 1.174-1.421), having a white or green priority code at arrival (low urgency) vs. the other ones (OR 1.195; 95% CI 1.100-1.297), and being aged ≤42 years old (OR 1.091; 95% CI 1.024-1.161).

CONCLUSION

The role of the GP is crucial in the management of PD and PAs. Given the difficulty of implementing primary and secondary prevention programs for these conditions, public health officials should make every effort to promote tertiary prevention in order to reduce the burden of the ailment and societal cost.

Associations between radius low-frequency axial ultrasound velocity and bone fragility in elderly men and women

An exploratory study in elderly women and men from the Geneva Retirees Cohort indicates that low-frequency quantitative ultrasound measurement at the radius captures aBMD, bone size, and cortical tissue mineral density and might be used for screening purposes prior to DXA to evaluate fracture risk_. INTRODUCTION: The contribution of distal radius bone mineral density (BMD) and cortical microstructure to fracture risk has recently been demonstrated. In this exploratory study, we investigated whether low-frequency quantitative ultrasound measurement at the distal radius may capture the peripheral determinants of bone fragility assessed with dual-energy X-ray absorptiometry (DXA) and high-resolution peripheral quantitative computed tomography (HR-pQCT).

METHODS

Low-frequency velocity (V_LF) was measured at the radius using OsCare Sono®, a portable axial transmission ultrasonometer, in 271 community-dwelling postmenopausal women and men (age 71.5 ± 1.4 years) from the Geneva Retirees Cohort. Cortical (Ct) and trabecular (Tb) volumetric (v) BMD and microstructure at the distal radius were assessed by HR-pQCT, in addition to areal (a) BMD by DXA, at the same time point.

RESULTS

V_LF was highly correlated with aBMD at the distal third radius (r = 0.72, p < 0.001). For microstructure parameters, the highest correlation was observed with cortical area (r = 0.59, p < 0.001). V_LF also captured bone geometry (total area) and cortical tissue mineral density independently of aBMD. In models adjusted for age and sex, V_LF was significantly associated with prevalent low-trauma fractures [OR 95%CI for one SD decrease of V_LF 1.50 (1.05, 2.14), p = 0.024], with discrimination performance comparable to femoral neck or distal radius aBMD.

CONCLUSION

Measurement of V_LF at the radius captures aBMD, bone size, and cortical tissue mineral density and might be used for screening purposes prior to DXA to evaluate fracture risk_.

Mediterranean diet and the risk of poor semen quality: cross-sectional analysis of men referring to an Italian Fertility Clinic

BACKGROUND

Several diet patterns have been suggested as involved in processes of spermatogenesis and thus in male subfertility. To study the relation between Mediterranean diet and abnormal sperm parameters in men of subfertile couples, we performed a cross-sectional analysis of baseline data from a prospective cohort study.

METHODS

Patients were enrolled in an Italian Fertility Clinic. Couples undergoing assisted reproduction techniques (ART) were interviewed to obtain information on personal and health history, lifestyle habits, and diet, on the day of oocyte retrieval. On the same day, a semen sample was also collected and analyzed to proceed with ART. Adherence to Mediterranean diet was evaluated using a Mediterranean Diet Score (MDS). Odds ratios (OR) and 95% confidence intervals (CI) were calculated for semen volume <1.5 mL, sperm concentration <15 mil/mL, and total count <39 mil.

RESULTS

Three hundred nine men, age range 27-60, were enrolled: 19.3% had semen volume < 1.5 mL, 30.5% sperm concentration <15 mil/mL, and 32.1% total count <39 mil. MDS was low (0-3) in 86 men (27.8%), intermediate (4-5) in 131 (42.4%), and high (6-9) in 92 (29.8%). Semen volume was not associated with MDS. Compared to the highest MDS category (6-9), the ORs for low sperm concentration were 1.34 (95% CI 0.69-2.50) for MDS 4-5 and 2.42 (95% CI 1.21-4.83) for MDS 0-3, with significant trend (p = 0.011). The corresponding estimates for total count were 1.26 (95% CI 0.66-2.42) and 2.08 (95% CI 1.05-4.12), with significant trend (p = 0.034). These findings were consistent in strata of history of reproductive organ diseases.

CONCLUSIONS

Mediterranean Diet Score was positively associated with normal sperm concentration and total count, but not with semen volume.

Correction to: New clotting disorders that cast new light on blood coagulation and may play a role in clinical practice

The original version of the article unfortunately contained few errors.