Assessment of postpartum perineal pain after vaginal delivery: prevalence, severity and determinants. A prospective observational study.

AIM: Perineal pain is present, after birth, in almost all (95-100%) women who have experienced perineal trauma. It has been shown that women with spontaneous vaginal delivery and minimal or absent perineal trauma will have better recoveries: less pain, more tonic perineal muscles, improved sexual function and lower rates of depression. The purpose of the present study was to prospectively assess the prevalence of perineal pain in a population of women with vaginal birth at term and physiological single newborn. METHODS: Pain assessment was performed using two subjective scales: the Verbal Numeric Scale (VNS) of 11 points and the Verbal Rating Score (VRS) of 4 points. Data collection period ran from the first postnatal day until 6 months after delivery, with two intermediate measurements at 1 and 7 weeks after birth. RESULTS: The study enrolled 451 women: 239 primiparous and 212 multiparous, with a response rate of 92% at 6 months. The prevalence of pain was found 88.2% in the first day postpartum, 62.3% one week after birth, 8.0% at seven weeks and 0.7% at six months. With regard to the resumption of sexual activity at 6 months postpartum, a dyspareunia rate of 27% was observed in the Episiotomy group (OR 5.72, P<0.001). CONCLUSION: The study found that an increase in the extent of trauma is associated with the highest scores in the self-assessment of perceived pain, with long term persistent symptoms. Furthermore, the presence of an episiotomy is a conditioning factor for the sexual function after childbirth (OR 0.43, P<0.001).

Alopecia areata and autoimmunity.

AIM: The aim of the present study was to estimate the association between alopecia areata (AA) and autoimmunity. To such scope, the authors have estimated the presence of autoantibodies in patients with alopecia areata joints to the authors' observation in the last two years. METHODS: In 63 patients affected with different forms of AA (45 cases with multiple patches, 10 with single patch, 5 with alopecia totalis and 3 with alopecia universalis), has been estimated a autoantibodies panel. In 28 subjects (44%) it has been evidenced the presence of autoantibodies; in particular, 23 subjects were affected from AA with multiple patches, 3 from single patch, 1 from alopecia totalis and 1 from alopecia universalis. RESULTS: The autoantibodies against thyroperoxidase and thyroglobulin were found more frequently, followed from antimicrosomal and antinuclear. Except in 5 subjects with autoimmune disease (4 from thyroiditis and 1 from subacute cutaneous lupus erythematosus), all the other cases turned out positives were asymptomatic, then the skin behaved like ''organ proof'' of an organ pathology. On this purpose, in 17 cases (27%) it has been revealed an autoimmune thyroiditis. CONCLUSION: AA is often associated to other autoimmune diseases and that in the 36% of the cases it has permitted to reveal a silent pathology of organ.

N-methyl-D-aspartate triggers neonatal rat hypoglossal motoneurons in vitro to express rhythmic bursting with unusual Mg2+ sensitivity.

The brainstem nucleus hypoglossus innervates the tongue which must contract rhythmically during respiration, chewing and swallowing. Such rhythmic discharges are due to network bursting mediated by AMPA receptor-dependent glutamatergic transmission. The contribution by hypoglossal motoneurons themselves to rhythmicity remains, however, unclear as they might simply express cyclic patterns produced by premotoneurons or, in analogy to spinal motoneurons, might participate to bursting due to activation of their N-methyl-D-aspartate (NMDA) receptors. Using patch clamp recording from hypoglossal motoneurons in slice preparations of neonatal rat brainstem, we observed that NMDA directly depolarized motoneurons to generate various discharge patterns. Most motoneurons produced transient bursts which were consistently restored by repolarizing membrane potential to rest. Fewer motoneurons generated either sustained bursting or random firing. Rhythmic bursts were recorded from XII nerve rootlets even when single motoneuron bursting required hyperpolarization. NMDA evoked bursts were blocked by the Ca2+ antagonist Cd2+, the gap junction blocker carbenoxolone, or Mg2+ free solution, and partially inhibited by tetrodotoxin or nifedipine. Under voltage clamp, NMDA-induced bursting persisted at negative or positive potentials and was resistant to high extracellular Mg2+ in accordance with the observation of widespread motoneuron expression of NMDA 2D receptor subunits that confer poor Mg2+ sensitivity. It is proposed that NMDA depolarized motoneurons with the contribution of Mg2+ insensitive channels, and triggered bursting via cyclic activation/deactivation of voltage-dependent Na+, Ca2+ and K+ currents spread through gap junctions. The NMDA-evoked bursting pattern was similar to the rhythmic discharges previously recorded from the XII nerve during milk sucking by neonatal rats.

The effects induced by the sulphonylurea glibenclamide on the neonatal rat spinal cord indicate a novel mechanism to control neuronal excitability and inhibitory neurotransmission.

BACKGROUND AND PURPOSE: Using the neonatal rat spinal cord in vitro, we investigated the action of glibenclamide, a drug possessing dual pharmacological effects, namely block of K(ATP) channels and of the cystic fibrosis transmembrane conductance regulator (CFTR). EXPERIMENTAL APPROACH: Intra- and extracellular recordings were performed on motoneurons and interneurons. RT-PCR and western immunoblotting were used to determine gene and protein expression. KEY RESULTS: Glibenclamide (50 microM) facilitated mono- and polysynaptic reflexes, hyperpolarized motoneuron resting potential, increased action potential amplitude, decreased Renshaw cell-mediated recurrent inhibition, and increased network excitability by depressing GABA- and glycine-mediated transmission. The action of glibenclamide was mimicked by tolbutamide (500 microM) or the CFTR blocker diphenylamine-2,2-dicarboxylic acid (500 microM). The action of glibenclamide was independent from pharmacological inhibition of the Na(+)-K(+) pump with strophanthidin (4 microM) and was associated with a negative shift in the extrapolated reversal potential for CI(-) dependent synaptic inhibition. On interneurons, intracellularly-applied 8-bromo-cAMP elicited an inward current and resistance decrease; effects antagonized by the selective CFTR antagonist, CFTR(inh)-172 (5 microM). RT-PCR and western immunoblotting indicated strong expression of the CFTR in neonatal rat spinal cord. CONCLUSIONS AND IMPLICATIONS: These data suggest the CFTR expressed in motoneurons and interneurons of the neonatal spinal cord is involved in the control of Cl(-) homeostasis and neuronal excitability. CFTR appeared to contribute to the relatively depolarized equilibrium potential for synaptic inhibition, an important process to control hyperexcitability and seizure-predisposition in neonates.

Early signs of motoneuron vulnerability in a disease model system: Characterization of transverse slice cultures of spinal cord isolated from embryonic ALS mice.

Mutations in the SOD1 gene are associated with familial amyotrophic lateral sclerosis. The mechanisms by which these mutations lead to cell loss within the spinal cord ventral horns are unknown. In the present report we used the G93A transgenic mouse model of amyotrophic lateral sclerosis to develop and characterize an in vitro tool for the investigation of subtle alterations of spinal tissue prior to frank neuronal degeneration. To this aim, we developed organotypic slice cultures from wild type and G93A embryonic spinal cords. We combined immunocytochemistry and electron microscopy techniques to compare wild type and G93A spinal cord tissues after 14 days of growth under standard in vitro conditions. By SMI32 and choline acetyl transferase immunostaining, the distribution and morphology of motoneurons were compared in the two culture groups. Wild type and mutant cultures displayed no differences in the analyzed parameters as well as in the number of motoneurons. Similar results were observed when glial fibrillary acidic protein and myelin basic protein-positive cells were examined. Cell types within the G93A slice underwent maturation and slices could be maintained in culture for at least 3 weeks when prepared from embryos. Electron microscopy investigation confirmed the absence of early signs of mitochondria vacuolization or protein aggregate formation in G93A ventral horns. However, a significantly different ratio between inhibitory and excitatory synapses was present in G93A cultures, when compared with wild type ones, suggesting the expression of subtle synaptic dysfunction in G93A cultured tissue. When compared with controls, G93A motoneurons exhibited increased vulnerability to AMPA glutamate receptor-mediated excitotoxic stress prior to clear disease appearance. This in vitro disease model may thus represent a valuable tool to test early mechanisms contributing to motoneuron degeneration and potential therapeutic molecular interventions.

[A vaccination campaign for gypsy children in Rome]. / Una campagna vaccinale in favore dei bambini Rom e Sinti a Roma.

Several studies conducted in Rome have shown low levels of vaccination coverage in gypsy communities. Thus a vaccination campaign targeting to 2400 gypsy children aged 0-13 years, present in 32 settlements in Rome, was conducted in 2002. The campaign was related to vaccinations required and recommended in Italy: diphtheria, tetanus, hepatitis B, pertussis (whooping cough), haemophilus influenzae and measles. In the majority of cases it was decided to carry out the vaccinations directly in the gypsy settlements, in accordance with the methods of pulse immunisation. In the case of small settlements a strategy for reorienting the population to vaccination centres was adopted. Around 2000 children were vaccinated, equivalent to 80% of the paediatric population present during the period. The number of children who have never been vaccinated has decreased from 40% prior to the campaign to 9% after the third week. Vaccination coverage in medium- and small-sized settlements (<200 inhabitants) after the campaign shows values of over 70%; in the large settlements, more modest increases have been recorded and coverage has rarely exceeded 50%. This experience has highlighted the importance of networking between public healthcare institutions and non-profit organisations. The mobilisation of a wide range of competences has thus enabled the attainment of a high level of effectiveness.

[National and international standards for limiting exposure to electromagnetic fields]. / Normativa internazionale e nazionale per la limitazione delle esposizioni a campi elettromagnetici.

Over recent years the possibility that adverse effects on health could result from exposure to electromagnetic fields has become one of considerable scientific, political and economic importance. In response to this, there has been intense activity, both at the international and national level, on the evaluation of biological effects literature and assessment of health hazards of human exposure to non-ionizing electromagnetic radiation. The health authorities of an increasing number of countries, including Italy, become involved in the development of recommendations, regulations or technical advice to limit the exposure of the workers and the general public and they are looking to the international organizations, particularly to the International Commission on Non-Ionizing Radiation Protection (ICNIRP), for some guidance in this respect. In this paper an attempt will be made to present a comparative analysis of the existing or recently proposed standards.

Do antenatal classes benefit the mother and her baby?

OBJECTIVE: To examine the characteristics of women attending antenatal classes and evaluate the effects of these classes on mothers' and babies' health. METHODS: A population-based observational study on care during pregnancy, delivery and in the postnatal period was carried out in 1995-96. A total of 9004 women resident in 13 regions of Italy who delivered in a 4-month period were interviewed. The outcomes studied were attendance at antenatal classes, Cesarean section, bottle feeding, satisfaction with the experience of childbirth, knowledge of contraception, breast feeding and baby care. RESULTS: A total of 2065 (23.0%) women attended antenatal classes. Women without previous children, those with a higher level of education and office workers were more likely to attend classes. Women who attended antenatal classes had a much lower risk of Cesarean section and were about half as likely to bottle feed while in hospital compared with non-attenders. They received better information on contraception, breast feeding and baby care. Women who attended classes and applied the techniques learned were more satisfied with the experience of childbirth. CONCLUSION: Antenatal classes seem to improve women's knowledge and competence. This may provide a defence against the tendency to overmedicalize pregnancy and childbirth.

A population-based study on the frequency of additional congenital malformations in infants with congenital hypothyroidism: data from the Italian Registry for Congenital Hypothyroidism (1991-1998).

In the last decade a high frequency of other congenital anomalies has been reported in infants with congenital hypothyroidism (CH) detected by neonatal screening. In the present study the occurrence of additional congenital malformations (CM) in the population of CH infants detected in Italy between 1991 and 1998 (n = 1420) was investigated. In Italy all of the centers in charge of screening, treatment, and follow-up of CH adhere to the Italian National Registry of infants with CH. In this study a high prevalence of additional CM (8.4%), more than 4-fold higher than that reported in the Italian population (1-2%), was found in the population of CH infants. Cardiac anomalies represented the most frequent malformations associated with CH, with a prevalence of 5.5%. However, a significant association between CH and anomalies of nervous system, eyes, and multiple CM was also observed. In conclusion, the significantly higher frequency of extrathyroidal congenital malformations reported in the CH infants than in the general population represents a further argument supporting the role of a genetic component in the etiology of CH. Investigations of the molecular mechanisms underlying developmental events of formation of thyroid and other organs represent critical steps in the knowledge of CH etiology.

Drug use in pregnancy among Italian women.

OBJECTIVE: To describe the use of drugs among Italian women during pregnancy and to compare it with other reports in Italy from the last 10 years. METHODS: A random sample of women who delivered in 1995-1996 were interviewed with regard to the care they received during pregnancy, delivery and the post-natal period. Information on antenatal care included maternal reports on the use of drugs during pregnancy. RESULTS: Of the 9004 women interviewed, 75% took at least one drug during pregnancy. Users took a median number of two drugs. Iron (51%) and vitamins (25%) dominate prescriptions throughout pregnancy. Fifteen percent of women reported treatment for threatened abortion and 27% for risk of pre-term delivery. The data do not differ from the drug exposure profile during pregnancy reported in other Italian studies. Logistic regression analysis of drug use (excluding haematologicals and nutritionals) shows an increased risk of usage for older women, the better educated, for those who reported health problems and those who had compulsory bed rest and/or hospitalisation during pregnancy. CONCLUSION: Seventy-five percent of the women reported use of at least one drug during pregnancy. Haematological and nutritional drugs are over prescribed. Although hormones have been clearly proven to be ineffective in preventing threatened abortion, the study shows an almost unchanged and out of date prescription pattern of progestational drugs. In order to avoid unnecessary exposure to potential risk, maternity care procedures should be reviewed and strictly related to an "evidence-based" approach.

Intercellular Ca2+ waves in mechanically stimulated articular chondrocytes.

Articular cartilage is a tissue designed to withstand compression during joint movement and, in vivo, is subjected to a wide range of mechanical loading forces. Mechanosensitivity has been demonstrated to influence chondrocyte metabolism and cartilage homeostasis, but the mechanisms underlying mechanotransduction in these cells are poorly understood. In many cell types mechanical stimulation induces increases of the cytosolic Ca2+ concentration that propagates from cell to cell as an intercellular Ca2+ wave. Cell-to-cell communication through gap junctions underlies tissue co-ordination of metabolism and sensitivity to extracellular stimuli: gap junctional permeability to intracellular second messengers allows signal transduction pathways to be shared among several cells, ultimately resulting in co-ordinated tissue responses. Mechanically-induced Ca2+ signalling was investigated with digital fluorescence video imaging in primary cultures of rabbit articular chondrocytes. Mechanical stimulation of a single cell, obtained by briefly distorting the plasmamembrane with a micropipette, induced a wave of increased Ca2+ that was communicated to surrounding cells. Intercellular Ca2+ spreading was inhibited by 18 alpha-glycyrrhetinic acid, suggesting the involvement of gap junctions in signal propagation. The functional expression of gap junctions was assessed, in confluent chondrocyte cultures, by the intercellular transfer of Lucifer yellow dye in microinjection experiments while the expression of connexin 43 could be detected in Western blots. A series of pharmacological tools known to interfere with the cell calcium handling capacity were employed to investigate the mechanism of mechanically-induced Ca2+ signalling. In the absence of extracellular Ca2+ mechanical stimulation induced communicated Ca2+ waves similar to controls. Mechanical stress induced Ca2+ influx both in the stimulated chondrocyte but not in the adjacent cells, as assessed by the Mn2+ quenching technique. Cells treatment with thapsigargin and with the phospholipase C inhibitor U73122 blocked mechanically-induced signal propagation. These results provide evidence that in chondrocytes mechanical stimulation activates phospholipase C, thus leading to an increase of intracellular inositol 1,4,5-trisphosphate. The second messenger, by permeating gap junctions, stimulates intracellular Ca2+ release in neighbouring cells. Intercellular Ca2+ waves may provide a mechanism to co-ordinate tissue responses in cartilage physiology.

Sex education in secondary schools: an Italian experience.

PURPOSE: To evaluate the impact on Italian teenagers' knowledge and attitudes of an experimental program in sex education. METHODS: The program consisted of five workshops in five public secondary schools in Rome. The impact of the program was evaluated with three questionnaires designed for this study. A pretest evaluated baseline knowledge, a posttest measured the gain in knowledge, and a third questionnaire estimated retention of information 4-6 months later. Three hundred seventy-six students attending secondary school participated in the program. Thirteen questions were selected for the analysis, and improvement was measured by the difference between pretest and posttest scores. RESULTS: Ninety-six percent of the sample was in favor of sex education programs in schools. The students had an average 50% gain in the percentage of correct answers following the course. The mean score based on the number of correct answers to questions showed a baseline value of 5.00, a posttest value of 11.80, and a test value 4-6 months later of 10.7. Results showed students' positive attitude toward school sex education courses, low baseline knowledge, and a good ability to learn. CONCLUSIONS: In Italy there is a need for collaboration between schools and local health services to promote knowledge and prevention in reproductive health among teenagers.

[Evaluation of the impact of birth preparation courses on the health of the mother and the newborn]. / Valutazione degli effetti dei corsi di preparazione alla nascita sulla salute della madre e del neonato.

In 1995-96 a knowledge, attitude and practise (KAP) survey on care during pregnancy, delivery and in the post-natal period was carried out by the National Institute of Health in Italy. Of the 9004 women interviewed, 23% have attended antenatal classes (36% in hospitals, 51% in maternal and child health, MCH, clinics and 13% privately). Women attending these classes tend to be well-educated, primigravidae and resident in the North. Women who attend antenatal classes, especially at MCH clinics, have a lower risk of caesarean section (OR = 0.60), of bottle feeding while in hospital (OR = 0.45) and of receiving no information on contraception (OR = 0.31). Women who attend classes and are able to apply the technique learnt have a reduced risk of being dissatisfied with the experience of childbirth (OR = 0.72), whereas the others have an increased risk of dissatisfaction (OR = 1.87).

Surveillance of acute flaccid paralysis in Italy: 1996-1997. AFP Study Group. Acute flaccid paralysis.

The last case of poliomyelitis due to transmission of indigenous wild poliovirus occurred in Italy in 1982. To achieve the certification of the eradication of poliomyelitis in Italy, an active surveillance of acute flaccid paralysis (AFP) in the population aged less than 15 years was set up following the World Health Organization (WHO) guidelines. The survey started in 1996 with a pilot study involving 4 out of 21 regions, and was gradually extended to a national level in 1997. The two-year survey identified five patients with diagnosis of vaccine associated paralytic poliomyelitis (VAPP). Polioviruses type 2 and 3 Sabin-like were isolated and characterized in three of them. In the remaining two cases, samples were collected late after the onset of symptoms, and poliovirus could not be isolated. No wild polioviruses were detected during the survey. The rate of non-polio AFP found in Italy in 1997 was 0.61 cases per 100,000, which is lower than the level of 1.0 case per 100,000 considered as acceptable by the WHO. This was mainly due to the delay in organizing the hospital network and starting the active search of AFP cases in the largest and most densely populated regions. Therefore, the overall rate of AFP found in Italy underestimates the global effectiveness of the program, which however will be better evaluated in the next few years. This study is the first systematic attempt to determine the rate of AFP in Italy.

Generation of rhythmic patterns of activity by ventral interneurones in rat organotypic spinal slice culture.

1. In the presence of certain excitatory substances the rat isolated spinal cord generates rhythmic oscillations believed to be an in-built locomotor programme (fictive locomotion). However, it is unknown whether a long-term culture of the same tissue can express rhythmic activity. Such a simplified model system would provide useful data on the minimal circuitry involved and the cellular mechanisms mediating this phenomenon. For this purpose we performed patch clamp recording (under whole-cell voltage or current clamp conditions) from visually identified ventral horn interneurones of an organotypic slice culture of the rat spinal cord. 2. Ventral horn interneurones expressed rhythmic bursting when the extracellular [K+] was raised from 4 to 6-7 mM. Under voltage clamp this activity consisted of composite synaptic currents grouped into bursts lasting 0.9 +/- 0.5 s (2.8 +/- 1.5 s period) and was generated at network level as it was blocked by tetrodotoxin or low-Ca2+-high-Mg2+ solution and its periodicity was unchanged at different potential levels. 3. In current clamp mode bursting was usually observed as episodes comprising early depolarizing potentials followed by hyperpolarizing events with tight temporal patterning. Bursting was fully suppressed by 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX) and reduced in amplitude and duration by N-methyl-D-aspartate (NMDA) receptor antagonism without change in periodicity. Extracellular field recording showed bursting activity over a wide area of the ventral horn. 4. Regular, rhythmic activity similar to that induced by K+ also appeared spontaneously in Mg2+-free solution. The much slower rhythmic pattern induced by strychnine and bicuculline was also accelerated by high-K+ solution. 5. The fast and regular rhythmic activity of interneurones in the spinal organotypic culture is a novel observation which suggests that the oversimplified circuit present in this culture is a useful model for investigating spinal rhythmic activity.

[Congenital forms of hypothyroidism: study of risk factors and preventive interventions]. / Forme congenite di ipotiroidismo: studio dei fattori di rischio e interventi di prevenzione. Gruppo di Studio per il Registro Nazionale degli Ipotiroidei Congeniti.

Maternal and child health represents one of the most relevant fields of interest in public health and particular attention is given to congenital pathologies. In Italy, the incidence of congenital hypothyroidism (CH) is 1:3200 live birth. CH is diagnosed at birth by neonatal thyroid screening. This allows a precocious onset of substitutive therapy which avoids severe psychomotor deficits in infants with CH. Moreover, the newborn screening program have permitted to identify transient disorders of thyroid function in newborns. These are essentially due to neonatal, maternal and environmental risk factors, especially iodine deficiency. The National Register (NR) of infants with CH was established in 1987. The aim of the NR is to provide disease surveillance and to monitor efficiency and effectiveness of neonatal screening. Furthermore, the NR represents an useful tool for developing epidemiological studies to identify possible environmental and/or familial risk factors of CH.

[Care in pregnancy, labor, and during the puerperium in Italy]. / L'assistenza in gravidanza, al parto e durante il puerperio in Italia.

In 1995-96 a KAP (knowledge, attitude and practice) survey on care during pregnancy, delivery and in the post-natal period was carried out in Italy by the National Institute of Health (Istituto Superiore di Sanità). A sample of 9004 women was interviewed in 13 regions within two months of the delivery. Care during pregnancy was generally at a good standard, but with an excessive use of some medical procedures. The level of knowledge was often low and some non-invasive but effective methods for preventing negative outcomes were not widely adopted. Many women were ill informed about the procedures to which they were subjected and their degree of satisfaction was often low. In general, a wide geographic variability and a lack of continuity in pre- and post-natal care were observed.