High mortality rate of oesophageal perforation is associated with delayed hospital admission : a prospective observational case series study.

BACKGROUND: To assess mortality rate of oesophageal perforation cases and study their etiology, diagnosis and management in a single specialized UK centre. PATIENTS AND METHODS: A prospective observational study was performed between January 2012 and January 2015. All consecutive patients admitted with acute iatrogenic or spontaneous esophageal perforation were included. Anastomotic leak patients were excluded. Patients were managed conservatively, endoscopically, surgically or with a combination of the above. Primary outcome was mortality rate and its association with time to hospital admission. Secondary outcomes were nature of perforation, anatomic location, type of management as well as length of hospital stay and surgical complication rate. RESULTS: There were 13 cases included. Mean patients' age was 58.3 years. Overall 90-day mortality rate was 38.4% (n=5), while 30-day mortality rate 30.8% (n=4). Admission within 24 hours of perforation was recorded in 69.2% of patients (n=9). The main anatomic location of perforation was the lower third of the esophagus in 53.8% (n=7). Operative management was adopted in 53.8% of cases (n=7). Mean hospital stay was 58.3 days. Mean follow-up was 3.1 years, while no patient developed any complication from the perforation or surgery. CONCLUSIONS: Mortality following esophageal perforation is at approximately 40%, while there is a significant impact of time of presentation on prognosis.

Maternal and perinatal outcomes after elective induction of labor at 39 weeks in uncomplicated singleton pregnancy: a meta-analysis.

OBJECTIVE: The rate of maternal and perinatal complications increases after 39 weeks' gestation in both unselected and complicated pregnancies. The aim of this study was to synthesize quantitatively the available evidence on the effect of elective induction of labor at 39 weeks on the risk of Cesarean section, and on maternal and perinatal outcomes. METHODS: PubMed, US Registry of Clinical Trials, SCOPUS and CENTRAL databases were searched from inception to August 2018. Additionally, the references of retrieved articles were searched. Eligible studies were randomized controlled trials of singleton uncomplicated pregnancies in which participants were randomized between 39 + 0 and 39 + 6 gestational weeks to either induction of labor or expectant management. The risk of bias of individual studies was assessed using the Cochrane Risk of Bias Tool. The overall quality of evidence was assessed according to the GRADE guideline. Primary outcomes included Cesarean section, maternal death and admission to the neonatal intensive care unit (NICU). Secondary outcomes included operative delivery, Grade-3/4 perineal laceration, postpartum hemorrhage, maternal infection, hypertensive disease of pregnancy, maternal thrombotic events, length of maternal hospital stay, neonatal death, need for neonatal respiratory support, cerebral palsy, length of stay in NICU and length of neonatal hospital stay. Pooled risk ratios (RRs) were calculated using random-effects models. RESULTS: The meta-analysis included five studies (7261 cases). Induction of labor was associated with a decreased risk for Cesarean section (moderate quality of evidence; RR 0.86 (95% CI, 0.78-0.94); I2  = 0.1%), maternal hypertension (moderate quality of evidence; RR 0.65 (95% CI, 0.57-0.75); I2  = 0%) and neonatal respiratory support (moderate quality of evidence; RR 0.73 (95% CI, 0.58-0.95); I2  = 0%). Neonates born after induction weighed, on average, 81 g (95% CI, 63-100 g) less than those born after expectant management. No significant effects were found for the other outcomes with the available data. The main limitation of our analysis was that the majority of data were derived from a single large study. A second limitation arose from the open-label design of the studies, which may theoretically have affected the readiness of the attending clinician to resort to Cesarean section. CONCLUSIONS: Elective induction of labor in uncomplicated singleton pregnancy at 39 weeks' gestation is not associated with maternal or perinatal complications and may reduce the need for Cesarean section, risk of hypertensive disease of pregnancy and need for neonatal respiratory support. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Anatomic distribution of endometriosis: A reappraisal based on series of 1101 patients.

OBJECTIVE: To reappraise the anatomic distribution of endometriosis lesions in cases with Superficial Implants (SI), Ovarian Endometrioma (OMA) and Deep Infiltrating Endometriosis (DIE). MATERIALS AND METHODS: A prospective observational study was operated between January 1989 to June 2009. A total of 1333 consecutive patients with a laparoscopic diagnosis of endometriosis, were extracted from our database. Due to missing data or repeated operations, 232 patients were excluded from the study. Finally, 1101 patients who met the selected criteria were included in the present analysis.. Primary outcome of study was the anatomic location of endometriotic lesions. Secondary outcomes were laterality of lesions as well as location of adhesions. RESULTS: Mean age of patients was 33.06 years (range 15-63 years) while the mean BMI was 21.5. The ovary was the most frequent site of endometriotic lesions (737 patients, 66.94%) followed by the utero-sacral ligaments (USL) (45.51%), the ovarian fossa (32.15%), the pouch of Douglas (29.52%) and the bladder (21.25%). Deep Infiltrating Endometriosis (DIE) was diagnosed in 159 patients (14.4%) with an increasing rate starting from the mid-nineties. The left side was predominant for all locations except fromr ovarian SI and fallopian tube, but for this latter location the number of cases was limited. 600 (54.4%) patients had adhesions wjth the adnexa being the most frequent site of location (47.4%). CONCLUSIONS: Ovary was the main site of endometriotic lesions followed by the utero sacral ligaments. Left side was predominant for all locations except for ovarian SI and fallopian tube. The diagnosis of DIE has constantly being increased since mid-nineties. The large cohort of patients included in the study has strengthened previous reported data.

Fluorescence in situ hybridisation sperm examination is significantly impaired in all categories of male infertility.

To study the outcome of FISH sperm examination in cases with sperm pathology and outline the potential correlation with certain chromosomal defects. A retrospective study of prospectively collected data was performed in IAKENTRO, Infertility Treatment Center. Rates of abnormal FISH semen examination were compared between male infertility patients and fertile controls. Detection of abnormal FISH semen examination as well as each chromosomal abnormality detected was correlated with each sperm deficiency (asthenozoospermia, oligozoospermia and teratozoospermia) in a univariate regression model. There were 72 male partners included, of which 52 male infertility patients and 20 controls. The rate of abnormal sperm FISH examination was significantly higher in patients' group (55.8% vs. 15.0% for controls, p = .002). Asthenozoospermia, oligozoospermia and teratozoospermia were significantly correlated with detection of abnormal FISH examination (p = .004, p = .01 and p < .001 respectively). Teratospermia was significantly correlated with increased aneuploidy rate for chromosome 17 (p = .005), chromosome X (p = .05) and Y (p = .03). FISH examination reveals pathology in a significant proportion of patients with sperm defects and should be recommended to achieve early detection of chromosomal defects that may postpone favourable reproductive outcome.

Does first-trimester nuchal cord affect the blood flow in the ductus venosus? A prospective observational study.

INTRODUCTION: Main objective of the present study was to investigate the association between the presence of nuchal cord (NC) and the measurement of the ductus venosus pulsatility index for veins (ductus venosus (DV) PIV). METHODS: This was a prospective study of 1974 singleton pregnancies that underwent first-trimester screening at 11-13+6 gestational weeks. Color Doppler was used to demonstrate the presence of a NC in all cases and the DV PIV was calculated routinely, as part of the standard scan. The association between the presence of a NC and the DV PIV was then examined overall and at each gestational week. RESULTS: A NC was demonstrated in 17.1% of cases. The incidence of nuchal cord was significantly higher at 13-13+6 weeks (24.7%, n = 119) compared to the one at 12-12+6 (16.5%, n = 192) and 11-11+6 weeks (7.9%, n = 26) (p < .001). No significant correlation was found between NC presence and DV PIV (p = .344). The DV PIV was 0.99 (± 0.15) for patients without NC versus 0.99 (± 0.15) for patients with NC (p = .34). CONCLUSIONS: There was no association between the presence of a NC at 11-13+6 gestational weeks and the DV PIV.

Finding the best therapeutic approach for PCOS: the importance of inositol(s) bioavailability.

Broadening clinical evidence has markedly designated inositol(s) as a common and effective therapeutic approach for PCOS and infertility. Although considerable research has been focused on the use in clinical practice of myo-inositol (myo-ins) and D-chiro-inositol (D-chiro-ins), the two major inositol stereoisomers, less attention has been paid to their bioavailability. Therefore, the aim of this paper is to gather and analyze information on inositol(s) bioavailability, to better delineate its optimal concentration for scientific and clinical purposes. Throughout the search in PubMed, Google Scholar, and ResearchGate we identified only two studies that investigated the pharmacokinetic (PK) profile of different myo-ins administrations. This analysis found no advantage in terms of PK for single 4 g dosing of myo-ins compared to 2 g twice a day, which allowed to get a 24-hour coverage, contrary to the singular dose. Indeed, the differences regarding the area under the curve (AUC) between the two PK profiles are linked only to the maximum concentration (Cmax) but not to the time variable. In conclusion, splitting the therapeutic dosage of 4 g myo-ins in two distinct administrations seems to be the best approach for a full-day coverage.

Epidemiology, diagnosis, and management of esophageal perforations: systematic review.

We performed a systematic review of epidemiological, diagnostic, and therapeutic outcomes of esophageal perforations. A systematic review was performed in PubMed database using the key-phrase 'esophageal perforation'. All studies regarding acute esophageal perforations were reviewed and parameters of epidemiology, diagnosis, and management published in the literature from 2005 up to 2015 were included in the study. Studies of postoperative esophageal leaks were excluded. Two researchers performed individually the research, while quality assessment was performed according to GRADE classification. Main outcomes and exposure were overall mortality, perforation-to-admission interval, anatomical position, cause, prevalent symptom at admission, diagnostic tests used, type of initial management (conservative or surgery), healing rate, and fistula complication. There were 1319 articles retrieved, of which 52 studies including 2,830 cases finally met inclusion criteria. Mean duration of study period was 15.2 years. Mean patient age was 58.4 years. Out of 52 studies included, there were 43 studies of very low or low quality included. The overall mortality rate according to extracted data was 13.3% (n = 214, 1,644 patients, 39 studies). Admission before 24 hours was reported in 58.1% of patients (n = 514). Position was thoracic in 72.6% of patients (n = 813, 1,120 patients, 20 studies). Mean cause of perforation was iatrogenic in 46.5% of patients (n = 899, 1,933 patients, 40 studies). Initial management was conservative in 51.3% of cases (n = 904, 1,762 patients, 41 studies) CT confirmed diagnosis in 38.7% of overall cases in which it was used as imaging diagnostic procedure (n = 266), X-ray in 36.6% (n = 231), and endoscopy in 37.4% (n = 343). Sepsis on admission was observed in 23.3% of cases (209 out of 898 patients, 16 studies). The present systematic review highlighted the significant proportion of cases diagnosed with delay over 24 hours, mortality rates ranging over 10% and no consensus regarding optimal therapeutic approach and optimal diagnostic management. As esophageal perforation represents a high-risk clinical condition without consensus regarding optimal management, there should be large multicenter prospective studies or Randomized Controlled Trial (RCT)s performed in order to advance diagnostic and therapeutic approach of such challenging pathology.

The use of serum anti-Mullerian hormone (AMH) levels and antral follicle count (AFC) to predict the number of oocytes collected and availability of embryos for cryopreservation in IVF.

AIM: To investigate the predictive value of anti-Mullerian hormone (AMH) and antral follicle count (AFC) on the final number of oocytes retrieved and the availability of embryos for cryopreservation in in vitro fertilization (IVF) cycles. PATIENTS AND METHODS: In this prospective study, one hundred and twenty women in their first IVF treatment were enrolled. The short stimulation agonist protocol was used for controlled ovarian hyperstimulation in all cases. Serum AMH levels were measured during the menstrual cycle preceding treatment. AFC was measured in cycle day 2, just before starting ovarian stimulation. RESULTS: A strong, positive correlation between AMH, AFC and the number of collected oocytes was found. The patients with available and suitable supplementary embryos for cryopreservation had higher levels of AMH and larger numbers of AFC. CONCLUSION: AMH and AFC appear to be valuable markers mainly for ovarian reserve and response to IVF treatment. Serum AMH levels and AFC are significantly associated with the number of retrieved oocytes. Also, a positive correlation with the availability of supernumerary embryos suitable for cryopreservation was observed.

Leptin increases luteinizing hormone secretion of fasting female rats.

PURPOSE: To investigate whether leptin acts directly on the anterior hypophysis by influencing gonadotropin secretion in vivo. MATERIALS AND METHODS: Cycling female rats were catheterised for frequent blood sampling and were either fasted or allowed free access to food. Stereotactic lesion of the medial preoptic area (MPOA) of the hypothalamus was performed in order to eliminate gonadotropin releasing hormone (GnRH) production. Leptin was administered at a dose of one mg/kg i.v. and blood samples were taken just before leptin administration and then after 30, 60, 90, 120, and 180 minutes. Plasma gonadotropin levels were determined. With completion of sampling, the brains were removed and the localisation of the lesions was verified histologically. RESULTS: Leptin at one mg/kg induced an increase in luteinizing hormone (LH) secretion in fasting rats, both in those with a lesion and those with intact medial preoptic area with a peak occurring 90 minutes after infusion. The augmenting effect was more prominent when the hypothalamus was intact. There was no effect in fed animals with or without lesion. Similarly, no effect was observed on follicle stimulating hormone (FSH) levels in any of the experimental groups. CONCLUSIONS: Leptin acts directly on the hypophysis enhancing LH but not FSH secretion. Nutritional state influences leptin's effect on the hypothalamus and the hypophysis.

Effectiveness of sublingual use of 400 mcg prostaglandin E1 for first trimester surgical abortion according to parity: a retrospective study.

AIM: The aim of this paper was to evaluate the effectiveness of sublingual use of misoprostol in women undergoing first trimester surgical abortion. Special consideration was given in a sub-group analysis according to parity. METHODS: A retrospective study was conducted, enrolling patients during 2006-2009. Pregnancies less than 12 weeks of gestation were exclusively included. Our sample was divided in: group 1, in which we included women who had received 400 mcg of misoprostol sublingually two hours before surgical abortion and group 2, with no use of misoprostol. Cervical dilatation and estimated blood loss (EBL) were compared between the two groups. Moreover, a sub-group analysis of the former parameters was made separately in nulliparous and multiparous women. RESULTS: Out of 79 patients included, 48 (60.75%) received misoprostol, while 31 (39.25%) did not. Cervical dilatation was significantly higher in group 1 (6.4±2.1 mm vs. 4.7±1.7 mm in group 2, P=0.001), while EBL was significantly lower in the same group (105.0±22.1 mL vs. 120.3±24.2 mL for group 2, P=0.005). Concerning the sub-analysis, cervical dilatation was significantly increased and EBL was significantly lower in multiparous receiving misoprostol comparing with those who did not (P=0.001 and P=0.002, respectively). However, the same parameters did not differ significantly between the two sub-groups of nulliparous women. CONCLUSION: Sublingual administration of 400mcg misoprostol is effective concerning cervical ripening and EBL in women undergoing first trimester surgical abortion. According to the results of the present clinical trial prostaglandin E1 is more effective in multiparous group of women.

Open versus closed vitrification of blastocysts from an oocyte-donation programme: a prospective randomized study.

The use of open carriers for embryo vitrification has raised safety concerns and therefore vitrification in closed systems has been proposed. However, the drop in the cooling rate emerges as a major drawback. The objective of the present study was to compare the efficiency of vitrification in open versus closed conditions. Blastocysts were randomly allocated either to open ultra-rapid vitrification (group I) or closed aseptic vitrification (group II). In group I, blastocysts were exposed to two solutions of ethylene glycol/dimethylsulphoxide (10%/10% and 20%/20%), while in group II, blastocysts were pretreated with a solution of lower concentration (5%/5%). A total of 208 and 224 vitrification-warming cycles were performed for groups I and II, respectively. Both groups were equal in terms of maternal age, sperm parameters and number and quality of blastocysts vitrified, warmed and transferred per cycle. Importantly, there was no significant difference between the groups in the analysed outcomes; embryo survival rate (84.1% versus 82.1%), clinical pregnancy rate (45.9% versus 42.4%), implantation rate (25.6% versus 24.5%), cycle cancellation rate (6.7% versus 8.5%) and live birth rate (41.2% versus 41.0%). These data suggest that ultra-rapid vitrification may be replaced by aseptic vitrification without affecting clinical efficiency.

Amniocentesis-related adverse outcomes according to placental location and risk factors for fetal loss after midtrimester amniocentesis.

PURPOSE OF INVESTIGATION: Amniocentesis-related adverse outcomes in singleton pregnancies and possible risk factors for fetal loss after mid-trimester amniocentesis performed in a single institution were investigated. METHODS: Amniocentesis-related adverse outcomes such as insufficient aspiration of amniotic fluid (AF), repeated puncture, and aspiration of hemorrhagic AF after mid-trimester amniocentesis were reviewed, while special consideration was given according to the placental location. Fetal loss rate up to 24 weeks of gestation and risk factors related to fetal losses were also investigated. RESULTS: 5,948 cases with the inclusion criteria were analyzed. Advanced maternal age was the most common indication (53%) for amniocentesis. A need for repeated puncture was overall 2.1% (n = 128) and was associated with a fundal placental location. Aspiration of hemorrhagic amniotic fluid was observed in 3.7% (n = 222) and was significantly associated with an anterior or fundal placental position. Fetal loss rate was 0.3% and there was no relationship with advanced maternal age (> or = 35 years), gestational age at amniocentesis > 18 weeks, repeated procedure, aspiration of hemorrhagic AF or placental location. CONCLUSION: Anterior or fundal placental position is a risk factor for amniocentesis-related adverse outcomes, however without significant contribution to the fetal losses. Placental location, advanced maternal age, amniocentesis gestational age > 18 weeks, and the procedure's adverse outcomes seem to have no impact on fetal loss rate.

Parity affects pregnancy outcomes in women 35 and older.

PURPOSE OF INVESTIGATION: The objective of the study was to examine the impact of parity on pregnancy outcomes in women 35 years and older. METHODS: The study was a retrospective cohort of singleton pregnancies of women aged > or = 35 years old during the period 2004-2008. Women were divided in two groups: group 1 included primigravidas and group 2 those with at least one past labor. Epidemiological characteristics, obstetric and neonatal outcomes were analyzed using the t test and chi-square test. RESULTS: 816 out of 5834 (14%) cases involved women aging > or = 35 years, 234 (28.7%) of which were nulliparous and 582 (61.3%) multiparous. Rate of cesarean section was 2.4 fold higher for primigravidas (p < .0001). Fetal distress, prolonged labor and Neonate Intensive Care Unity (NICU) admission were also significantly higher in group 1. CONCLUSION: Adverse pregnancy outcomes were increased in primigravidas of 35 years and older compared to multigravidas of the same age.

Epidemiological characteristics and trends of caesarean delivery in a University Hospital in Northern Greece.

BACKGROUND: Current obstetric practice is characterised by a continuous increase in caesarean section (CS) delivery rates. OBJECTIVE: Main purpose of our study was to estimate the overall and annual rates of CS in a University Hospital in Greece. METHODS: This was a retrospective chart review of all singleton pregnancies delivered by CS between 2004 and 2008 at a gestational age > 24 weeks. The overall and annual CS rates were calculated. The rate of elective (Group 1) and emergency CS (Group 2) , as well as the specific indications in the two groups of the study were also analyzed. RESULTS: Overall 5362 singleton pregnancies were delivered in the period of the study. The overall CS rate was 29.2% (n = 1564). The mean ±SD maternal age in years of the women delivered by CS was 29.65 ± 6.72 years, while it was 27.10 ±5.63 years for those who delivered vaginally (P<0.0001). The overall rates of elective and emergency CS were 18.2% and 11.0% respectively in the 5-year period of the study. The most common indication for an elective CS was a previous CS (63.1%), which remained almost stable during the period of the study. The main indication for emergency CS was foetal distress in the first three years of the study, while labour progress failure was the leading indication in the last two years. CONCLUSION: In this series, the overall CS rate was high. A previous caesarean delivery accounts for about one third of all cases and constitutes the leading indication for elective CS while foetal distress is the most common indication for an emergency caesarean section.