1,721,008 research outputs found
Ruolo del Rapporto Neutrofili-Linfociti (NLR) nella valutazione del rischio di recidiva di neoplasia intraepiteliale cervicale di alto grado (CIN2+) dopo trattamento chirurgico
No full textIl principale fattore di rischio coinvolto nella recidiva di lesioni cervicali di alto grado relate all’infezione da Papillomavirus Umano (HPV) CIN2+ dopo trattamento chirurgico, sono da ritrovarsi nella persistenza dell’infezione medesima e nel fallimento conseguente della clearance virale da parte del sistema immunitario dell’ospite. La de-regolazione dell’immunità cellulare consente ai genotipi di HPV al alto rischio oncogeno (HR-HPV) di trasformarsi in “un’infezione persistente trasformante” che promuove lo sviluppo delle lesioni di alto grado e del carcinoma della cervice uterina e il conseguente aumentato rischio di recidiva dopo il trattamento chirurgico. In tale contesto, la progressione neoplastica è inoltre caratterizzata da un’incrementata produzione di citochine IL6, IL17, IL8, stimolanti i linfociti TH2, e una ridotta espressione di IL1, TNF-alpha, TGF-beta, INF-gamma, cui segue un mancato richiamo dei linfociti TH1. Si assiste quindi al crearsi di uno squilibrio tra i linfociti TH2 CD4+ e i linfociti TH1 CD8+, così repressi. Un possibile indicatore clinico dell’alterazione immunologica nelle infezioni cervicale indotti da HPV è rappresentato calcolo del rapporto neutrofili-linfociti (NLR). Lo scopo dello studio è stato analizzare il ruolo predittivo della NLR nella recidiva di CIN di alto grado (CIN2+) dopo trattamento escissionale mediante tecnica leep.
Sono stati analizzati in modo retrospettivo i dati clinici, demografici, virologici, biochimici e istologici di 444 pazienti, arruolate presso il Servizio di Colposcopia del Dipartimento di ginecologia e ostetricia, IRCCS Fondazione Policlinico San Matteo di Pavia, dal 2011 al 2020. Le pazienti sono afferite presso il suddetto centro di patologia del basso tratto genitale per un pap test di screening anomalo. I dati sono stati confrontati con il valore di NLR, calcolato dai dati derivati dal valore assoluto di linfociti e neutrofili al momento della diagnosi.
Tutti le pazienti analizzate sono state trattate secondo un protocollo stabilito: (colposcopia ogni 6 mesi per i primi due anni, e ogni anno oltre i tre anni,) HPV-DNA test, biopsia cervicale (esocervicale e/o endocervicale) eseguita all'ingresso e alla fine del follow-up. Tutti le pazienti sono state sottoposte a un prelievo di sangue periferico venoso, per il conteggio dei globuli bianchi, dei neutrofili e dei linfociti (valori espressi come 10^3 /ml).
La sensibilità (SE) e la specificità (SP) del cut-off di NLR di 1.34 per la diagnosi di recidiva di CIN2+
è stato rispettivamente di 0.76 e 0.67. Il rischio di recidiva di CIN2+ è stato significativamente più elevato nelle pazienti con NLR < 1.34 (3.7% vs 0.6%, p = 0,033). La sopravvivenza libera da recidiva a 5 anni di Follow-up è stata più elevata nelle pazienti con NLR ≥ 1.34 (97% vs. 93%, p=0,030).
Tale studio mostra come possibili limitazioni due fattori principali; da una parte l’analisi retrospettiva e la bassa incidenza di recidiva possono limitare le conclusioni. In aggiunta, per il disegno retrospettivo dello studio non sono state prese in considerazione nell’analisi multivariata le comorbidità delle pazienti e abitudini di vita come il fumo, che possono influenzare il valore di NLR. D'altra parte, la durata media del follow-up nel nostro studio è stata però di 26 mesi (IQR 22-31), che riflette pienamente l’incidenza di ricorrenza di recidiva di CIN2+.
In conclusione, sebbene sia noto che le lesioni CIN2+ sono sostenute da una de-regolazione del sistema immunitario causata da infezione persistente da HPV, tra i fattori determinati tale alterazione del microambiente immunologico, i linfociti sono i determinanti della persistenza virale. Per tale motivo il calcolo del NRL potrebbe essere un biomarcatore affidabile ed economicamente vantaggioso nel prevedere il rischio di recidiva soprattutto per lesioni cervicali di alto grado in ambito clinico.The main risk factor involved in the recurrence of high-grade cervical lesions related to Human Papillomavirus (HPV) CIN2+ infection after surgical treatment is found in the persistence of the infection and the consequent failure of viral clearance by the immune system. Deregulation of cellular immunity allows HPV genotypes with high oncological risk (HR-HPV) to arrive to “transforming persistent infection” that promotes the development of high-grade lesions and cervical cancer and subsequent increased risk of recurrence after surgical treatment. In this context, neoplastic progression is also characterized by an increased production of cytokines IL6, IL17, IL8, which stimulate TH2 lymphocytes, and a reduced expression of IL1, TNF-alpha, TGF-beta, INF-gamma, followed by a failure to recall TH1 lymphocytes. We therefore witness the creation of an imbalance between the TH2 CD4+ lymphocytes and the TH1 CD8+ lymphocytes, thus repressed. A possible clinical indicator of immunological alteration in HPV-induced cervical infections is represented by calculation of the neutrophil-lymphocyte ratio (NLR). The aim of the study was to analyze the predictive role of NLR in the recurrence of high-grade CIN (CIN2+) after excisional treatment using the leep technique.
The clinical, demographic, virological, biochemical and histological data of 444 patients enrolled in the Colposcopy Service of the Department of Gynecology and Obstetrics, IRCCS Fondazione Policlinico San Matteo di Pavia, from 2011 to 2020 were retrospectively analyzed. The patients referred to the center for an abnormal screening pap test. The data were compared with the NLR value, calculated from data derived from the absolute value of lymphocytes and neutrophils at the time of diagnosis.
All patients analyzed were treated according to an established protocol: (colposcopy every 6 months for the first two years, and every year beyond three years) HPV-DNA test, cervical biopsy (esocervical and/or endocervical) performed on admission and at the end of the follow-up. All patients underwent a venous peripheral blood sample to count white blood cells, neutrophils and lymphocytes (values expressed as 10^3 /ml).
The sensitivity (SE) and specificity (SP) of the NLR cut-off of 1.34 for the diagnosis of CIN2+ recurrence was 0.76 and 0.67, respectively. The risk of CIN2+ recurrence was significantly higher in patients with NLR < 1.34 (3.7% vs 0.6%, p = 0.033). Recurrendce-free survival at 5 years of follow-up was higher in patients with NLR ≥ 1.34 (97% vs. 93%, p=0.030).
This study reporting the following limitation: the retrospective analysis and the low incidence of recurrence may limit the conclusions. In addition, due to the retrospective design of the study, patient comorbidities and lifestyle habits such as smoking were not taken into consideration in the multivariable analysis. On the other hand, the median duration of follow-up in our study was 26 months (IQR 22-31), which fully reflects the incidence of CIN2+ recurrence.
In conclusion, although it is well known that CIN2+ lesions are supported by a deregulation of the immune system caused by persistent HPV infection, among the factors determining this alteration of the immunological microenvironment, lymphocytes are the determinants of viral persistence. For this reason, the calculation of the NRL could be a reliable and cost-effective biomarker in predicting the risk of recurrence, especially for high-grade cervical lesions in the clinical setting
Respiratory Syncytial Virus in Pregnancy: An Obstetrics View
No full textRespiratory syncytial virus (RSV) represents one of the most prevalent causes of lower respiratory tract infection in newborns and children by the time they are two years old, with a peak rate of hospitalization in those between two and three months of age and a high risk of morbidity and mortality, especially under the age of six months of life [...
Adrenal crisis during pregnancy: Case report and obstetric perspective
No full textAdrenal dysfunction (AD) and, in particular, adrenal crisis are uncommon events in pregnant women, but associated with significant maternal and fetal morbidity and mortality if untreated or undiagnosed. Adrenal crisis may be confused with the common symptoms of pregnancy: the obstetricians should be able to promptly diagnose and treat it in order to avoid the adverse outcomes regarding the mother and the fetus. For this reason, AD must be treated by an expert multidisciplinary team. We presented a case report of a young pregnant woman with adrenal crisis due to tuberculosis, cocaine abuse, and massive bilateral hemorrhage with symptoms of emesis, hypotension, sudden abdominal pain, and leukocytosis. The most common issues of diagnosis and treatment are discussed and analyzed. Finally, we performed a review of the literature regarding adrenal crisis and adrenal insufficiency (AI) in pregnancy in order to clarify the management of these diseases in obstetrics setting
What is known about neuroplacentology in fetal growth restriction and in preterm infants: A narrative review of literature
Full text linkThe placenta plays a fundamental role during pregnancy for fetal growth and development. A suboptimal placental function may result in severe consequences during the infant’s first years of life. In recent years, a new field known as neuroplacentology has emerged and it focuses on the role of the placenta in fetal and neonatal brain development. Because of the limited data, our aim was to provide a narrative review of the most recent knowledge about the relation between placental lesions and fetal and newborn neurological development. Papers published online from 2000 until February 2022 were taken into consideration and particular attention was given to articles in which placental lesions were related to neonatal morbidity and short-term and long-term neurological outcome. Most research regarding the role of placental lesions in neurodevelopment has been conducted on fetal growth restriction and preterm infants. Principal neurological outcomes investigated were periventricular leukomalacia, intraventricular hemorrhages, neonatal encephalopathy and autism spectrum disorder. No consequences in motor development were found. All the considered studies agree about the crucial role played by placenta in fetal and neonatal neurological development and outcome. However, the causal mechanisms remain largely unknown. Knowledge on the pathophysiological mechanisms and on placenta-related risks for neurological problems may provide clues for early interventions aiming to improve neurological outcomes, especially among pediatricians and child psychiatrists
Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: a systematic review and meta-analysis
No full textBackground: Genital gender-affirming surgery has become a crucial step in the transitioning process of numerous transgender people. Aim: To highlight the consequences of genital gender-affirming surgery on pelvic floor function in transgender people. Methods: Medical databases (PubMed, EMBASE, and Cochrane Library) were consulted according to a combination of keywords. All papers published up to February 29, 2024 were considered. Two reviewers independently screened the abstracts of the selected studies and extracted data from the full-text articles included. Data were subsequently tabulated and compared for consistency. The bias associated with each included study was evaluated according to the Observational Study Quality Evaluation (OSQE) method. This study is registered on PROSPERO number CRD42024522580. Outcomes: Pelvic floor dysfunctions in individuals who undergo gender-affirming surgery, factors that may be involved in the increased prevalence of these dysfunctions and perspectives of treatment of the complications through pelvic floor physical therapy. Results: Twenty-five papers were considered for systematic review, while 17 studies were included for meta-analysis. There was significant statistical heterogeneity across the included studies. Among transwomen who had undergone vaginoplasty, pelvic organ prolapse occurred in 1%-7.5% of patients, urinary incontinence affected up to 15% of patients, while urinary irritative symptoms up to 20%. Sexual dysfunctions were reported by 25%-75% of patients. Among transmen who underwent hysterectomy and phalloplasty, pelvic organ prolapse occurred in 3.8% of patients, urinary incontinence affected up to 50% of patients, while urinary irritative symptoms up to 37%. Finally, sexual dysfunctions were reported by 54% of patients. Clinical implications: The findings of this study could be helpful for transgender patients pre-operative counselling. Strengths and limitations: This is the first systematic review and meta-analysis about pelvic floor dysfunctions in transgender people undergoing genital gender-affirming surgery. The main limitations are the limited number of studies included and their heterogeneity. Conclusion: Pelvic floor dysfunctions following genital gender-affirming surgery are an emerging issue. Adequate information for each surgical procedure, explicit postoperative instructions, continuity of care, communication with healthcare providers, and recommendation for tailored perioperative pelvic floor physiotherapy are necessary for a better surgical result
Multiple human papillomavirus infection and high-grade cervical squamous intraepithelial lesions among women with human immunodeficiency virus: a systematic review and a meta-analysis
No full textBackground: This study aimed to evaluate the prevalence of multiple high-risk (HR) human papillomavirus (HPV) infections in women with human immunodeficiency virus (HIV) compared to negative controls. This study also aimed to assess the impact of multiple HR-HPVs on the risk of high-grade squamous cervical lesions (HSILs) among women with HIV. Methods: We performed a systematic search of PubMed/Medline, Scopus, Cochrane databases, and ClinicalTrials.gov from 1 January 2004 to 30 June 2023, including screenings and clinical studies evaluating the rates and role of multiple HPV infections in squamous intraepithelial lesions (SILs). Three reviewers independently screened the abstracts of the selected studies and extracted data from full-text articles. The data were subsequently tabulated and compared for consistency. The bias associated with each included study was evaluated according to the OSQE method. Results: Forty-seven studies meet definitive inclusion criteria. The quality of the observations was considered low in 26 of the included studies and moderate in 21 of the included studies. In comparative screening studies, the pooled prevalence of multiple HR-HPV was 39.1% (95% CI = 33.7–44.7) among women with (n = 1734) and 21.6% (95% CI = 17.3–26.1) in those without HIV infection (n = 912) (OR = 2.33, 95% CI = 1.83–2.97, I2 = 2.8%). The pooled ORs of HR-HPV multiple infections were similar in African (OR = 2.72, 95% CI = 1.89–3.9) and non-African countries (OR = 2.1, 95% CI = 1.46–3, p for difference = 0.96). Among women with HIV, the risk of HSIL diagnosed either by cytology or histology was higher among those with overall (OR = 2.62, 95% CI = 1.62–4.23) and HR multiple infections than those with single HPV infection (OR = 1.93, 95% CI = 1.51–2.46). Among women with HIV, the excess rates of multiple HPV infections and the excess risk of associated HSIL were consistent across studies including both HIV-naïve subjects and those on antiretroviral therapy, as well as in studies with different rates of immunocompromised women. When study quality (low vs. moderate) was used as a moderator, the results were unchanged. Conclusion: Multiple HR-HPV infections are common among women living with HIV and are associated with an increased prevalence of HSIL. These associations were also confirmed in studies with high rates of antiretroviral therapy and low rates of immunocompromise. Systematic Review Registration: PROSPERO [registration number: CRD42023433022]
Aging of Pelvic Floor in Animal Models: A Sistematic Review of Literature on the Role of the Extracellular Matrix in the Development of Pelvic Floor Prolapse
No full textPelvic organ prolapse (POP) affects many women and contributes significantly to a decrease in their quality of life causing urinary and/or fecal incontinence, sexual dysfunction and dyspareunia. To better understand POP pathophysiology, prevention and treatment, many researchers resorted to evaluating animal models. Regarding this example and because POP affects principally older women, our aim was to provide an overview of literature on the possible biomechanical changes that occur in the vaginas of animal models and their supportive structures as a consequence of aging. Papers published online from 2000 until May 2021 were considered and particular attention was given to articles reporting the effects of aging on the microscopic structure of the vagina and pelvic ligaments in animal models. Most research has been conducted on rodents because their vagina structure is well characterized and similar to those of humans; furthermore, they are cost effective. The main findings concern protein structures of the connective tissue, known as elastin and collagen. We have noticed a significant discordance regarding the quantitative changes in elastin and collagen related to aging, especially because it is difficult to detect them in animal specimens. However, it seems to be clear that aging affects the qualitative properties of elastin and collagen leading to aberrant forms which may affect the elasticity and the resilience of tissues leading to pelvic floor disease. The analysis of histological changes of pelvic floor tissues related to aging underlines how these topics appear to be not fully understood so far and that more research is necessary
Outcome of Persistent Low-Grade Cervical Intraepithelial Neoplasia Treated With Loop Electrosurgical Excision Procedure
No full textAnalysis of surgical outcomes and learning curve of surgical parameters for robotic hysterectomy: a comparison between multiport versus single-site
No full textIntroduction: The primary goal is to analyze the learning curve of surgical parameters (docking, operation and console time) between multiport and single-site robotic hysterectomy techniques, performed by expert laparoscopic surgeons. Material and methods: The trial is a retrospective analysis of 229 patients enrolled between 2010 and 2018 who underwent robotic hysterectomies with bilateral salpingo-oophorectomies (HBSO) for gynecological diseases. Results: Surgical parameters, learning curve and surgical outcomes were analyzed in order to evaluate the transition from multiport to single-site programs, performed by non-expert surgeons using the multiport technique. All surgical times (total, docking and console time) were shorter in the multiport robotic hysterectomy group, while the intraoperative complication rate was lower in the robotic single-site hysterectomy group (p = 0.007). The learning curve of operative, console and docking time significantly decreased more in the robotic-single site hysterectomy group, than in the multiport robotic hysterectomy group over time (p value < 0.001). Conclusions: The direct transition from the laparoscopy program to the single-site approach is feasible and effective in HBSO performed by expert laparoscopic surgeons. The learning curve of robotic single-site hysterectomy shows that the proficiency in this technique requires more cases than the multiport robotic hysterectomy cases and needs more time to fit the surgical step to the single-site platform
Single-site Versus Multiport Robotic Hysterectomy in Benign Gynecologic Diseases: A Retrospective Evaluation of Surgical Outcomes and Cost Analysis
No full textObjective: To compare the surgical outcomes and costs of robotic-assisted hysterectomy with the single-site (RSSH) or multiport approach (RH). Design: A retrospective analysis of a prospectively collected database (Canadian Task Force classification II1). Setting: A university hospital. Patients: Consecutive women who underwent robotic-assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for the treatment of benign gynecologic diseases. Interventions: Data on surgical approach, surgical outcomes, and costs were collected in a prospective database and retrospectively analyzed. Measurements and Main Results: The total operative time, console time, docking time, estimated blood loss, conversion rate, and surgical complications rate were compared between the 2 study groups. Cost analysis was performed. One hundred four patients underwent total robotic-assisted hysterectomy and bilateral salpingo-oophorectomy (45 RSSH and 59 RH). There was no significant difference in the indications for surgery and in the characteristics of the patients between the 2 study groups. There was no significant difference between the single-site and multiport approach in console time, surgical complication rate, conversion rate, and postoperative pain. The docking time was lower in the RH group (p = .0001). The estimated blood loss and length of hospitalization were lower in the RSSH group (p = .0008 and p = .009, respectively). The cost analysis showed significant differences in favor of RSSH. Conclusion: RSSH should be preferred to RH when hysterectomy is performed for benign disease because it could be at least as equally effective and safe with a potential cost reduction. However, because of the high cost and absence of clear advantages, the robotic approach should be considered only for selected patients
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