Rationale and design for the Vaginal Erbium Laser Academy Study (VELAS): an international multicenter observational study on genitourinary syndrome of menopause and stress urinary incontinence.

The genitourinary syndrome of menopause (GSM) and stress urinary incontinence (SUI) are common clinical challenges for women's health and quality of life. The laser treatment and particularly the vaginal erbium laser (VEL) may provide a new non-invasive treatment for both GSM and SUI. However, the estimation of the ultimate results of different laser treatments may be altered by different issues, such as patient selection, concomitant treatments, and long-term effect of vaginal laser thermotherapy. In the present paper, we present the protocol for a large multicenter study on the evaluation of the efficacy and safety of VEL for the treatment of GSM and SUI, the Vaginal Erbium Laser Academy Study (VELAS). This study will evaluate the effects of three laser applications in 1500 postmenopausal women. Subjective and objective symptoms will be evaluated prior to the first laser treatment with follow-up visits after 4 weeks from the last laser application, and subsequently after every 3 months for 1 year. Findings from the VELAS have the potential to affect clinical care practice and health decisions for millions of women world-wide for a non-hormonal treatment for GSM and a non-invasive treatment of SUI.

Cumulative trauma disorders of the upper limbs in workers on an agricultural farm.

The work associated with repetitive efforts and inadequate resting periods, strong physical exertion, awkward postures or static positioning exposes workers to the risk of cumulative trauma disorders of the upper limbs. These risk factors are present in many agricultural activities. A study was carried out among workers on an agricultural farm. The workers' histories were taken and they were given periodical medical check-ups. The presence of upper limb disorders was shown in a group of workers. A sample of 42 people was selected for the study by means of specific tests: electromyography, ultrasonography and laser-doppler flowmetry. The tests showed a high incidence of carpal tunnel syndrome and microcirculation disorders. The study confirmed that electromyography, ultrasonography and/or laser-doppler flowmetry are highly useful tools for identifying cumulative trauma disorders.

Assessment of human exposure to pesticides in greenhouses and effectiveness of personal protective devices.

The exposure to pesticides in a group of workers growing vegetables in greenhouses in farms near Rimini in Italy was evaluated. The pesticides used were organophosphorus compounds, organochlorine compounds, carbamates, pyrethroids, amide and anilide derivatives. Measurements were carried out in seven greenhouses randomly selected. The environment was free of atmospheric agents which could have influenced the pesticide concentrations in the indoor air. Two types of chemical sampling were performed: environmental and personal. The latter was done in the liquid for washing hands and by means of pads applied directly to the worker's skin and to the clothes. The aim of the determination of airborne pesticide concentrations was to evaluate mean environmental exposure to pesticides in the sprayed areas. The sampling went on from a fixed point during the entire spraying period. The aim of individual sampling was to determine the active ingredients as contaminants. The values obtained showed a risk of exposure for the greenhouse personnel working without using personal protective devices (masks, gloves and waterproof clothes), considering that pesticides could be absorbed through the skin in between the spraying intervals.

[Entrapment of the ulnar nerve at the elbow caused by repetitive movements: description of a clinical case]. / Intrappolamento del nervo ulnare al gomito da movimenti ripetitivi: descrizione di un caso clinico.

The paper describes a case of ulnar neuropathy in a man who made household fittings and toys using bamboo. Several years after starting the job he showed symptoms and physical signs of ulnar nerve entrapment at the elbow, which were confirmed by electrophysiological findings. Job analysis revealed biomechanical risk factors consisting of a high repetition of forceful flexion and extension of the elbow, wrist and fingers without sufficient rest periods. Chronic musculoskeletal overuse gradually leads to tendon and nerve disorders. The ulnar neuropathy described can be classed under cumulative occupational trauma, which is the most important cause of musculoskeletal disorders among the working population.

Human decidua and in vitro decidualized endometrial stromal cells at term contain immunoreactive corticotropin-releasing factor (CRF) and CRF messenger ribonucleic acid.

CRF, a hypothalamic neurohormone, has been shown to be present in several tissues outside the brain. During pregnancy, both fetal (placental trophoblast, chorion, and amnion) and maternal (decidua) intrauterine tissues contain immunoreactive CRF. A paracrine/autocrine role of CRF as a regulator of hormonogenesis in human placenta and decidua has been suggested. The expression of CRF mRNA in human decidua was demonstrated in the present study by Northern blot analysis and was found to be higher in specimens collected at term than in those collected during the first and second trimesters of gestation. Furthermore, the presence of CRF was detected immunocytochemically in cultured decidual cells isolated from term decidua as well as in endometrial stromal cells decidualized in vitro by treatment with a mixture of medroxyprogesterone acetate, estradiol, and relaxin. These results indicate that human decidua is an intrauterine extrahypothalamic source of CRF in the maternal compartment and offer new tools to explore the in vitro decidualization processes and the regulation of CRF release from decidual cells.

In vitro decidualization of human endometrial stromal cells.

Stromal cells isolated from proliferative human endometrium undergo morphologic and biochemical changes when exposed to a mixture of ovarian hormones, acquiring characteristics of decidual cells. In addition to the previously reported progestin-induced secretion of prolactin (PRL) by explants of human proliferative endometrium, and of PRL and laminin by stromal cells in culture, "in vitro" induction of several other decidual cell products was demonstrated in the present study, using cultures of stromal cells isolated from proliferative endometrium. Incubation of stromal cells with a mixture of estradiol, medroxyprogesterone acetate and relaxin, at a concentration reported to yield maximal stimulation of PRL production, resulted in changes from elongated to rounder cells, approx. 90% of which showed immunostaining for PRL under these conditions. Immunocytochemical procedures were carried out on cytospins of decidual cells isolated from decidual tissue adherent to fetal membranes collected at delivery (positive controls), and on stromal cells cultured in Lab-Tek chamber-slides, in the absence (negative controls) or in the presence of added hormones. Antibodies to 24K (a heat-shock protein also named HRP27), desmin (present in intermediate filaments), p29 (a protein associated with the estrogen receptor), and PP12 (an insulin growth factor-1 binding protein), did not react with stromal cells isolated from proliferative endometrium but showed immunostaining of the rounder cells obtained after hormonal treatment when tested with the peroxidase-labeled second antibody complex. In another series of similar experiments, in which the same decidualization end-points were employed, changes in 24K, desmin and PP12 expression were obtained by adding to the insulin-containing medium PRL instead of the hormonal mixture, a finding suggesting sequential steps during the decidualization process.

Estrone sulfate sulfatase activity is increased during in vitro decidualization of stromal cells from human endometrium.

Arylsulfatase (EC 3.1.6.1) activity in human stromal cells isolated from specimens of histologically normal proliferative endometrium was increased several-fold during culture for 8-15 days in RPMI-1640 medium plus 10% charcoal-treated fetal bovine serum in the presence of a mixture of ovarian hormones (36 nM estradiol, 1 microM medroxyprogesterone acetate, and 100 micrograms/mL relaxin). The changes in sulfatase activity, determined by measuring the rate of formation of estrone from tritiated estrone sulfate, were associated with in vitro decidualization of the stromal cells, as determined by changes in secretion of PRL into daily renewed culture medium. PRL output by the cells during the last 24 h in culture and sulfatase activity in the cells collected at the end of the culture period were related to their DNA and protein contents. Sulfatase activity in the cells cultured in the presence of the ovarian hormones was comparable to the activity found in decidual cells at term pregnancy. PRL added for 1 day to cultures of stromal cells in the absence of exogenous hormones increased sulfatase activity in the cells, probably by acting in an autocrine manner, as previously demonstrated with human decidual cells during pregnancy. These experiments also revealed a hormonal regulation of stromal cell proliferation in vitro, as estimated from measurements of both DNA and protein levels per dish. Augmentation of sulfatase activity can serve as another marker of in vitro decidualization. Physiologically, an increase in this enzymatic activity may result in a preferential estrogenic stimulation of the decidualized cells by utilization of a circulating substrate, estrone sulfate. This hypothesis could explain the preferential retention of progesterone receptors in decidual cells observed immunohistochemically during the late luteal phase of the menstrual cycle, suggestive of a shift in progestogenic actions from the epithelium to the stroma.

Extraction of estrogens by human perfused uterus. Effects of membrane permeability and binding by serum proteins on differential influx into endometrium and myometrium.

The present study was undertaken to examine the extractions of estradiol, estrone, and estrone sulfate from the circulation of the human perfused uterus. The differential permeability of endometrial and myometrial vascular beds to estrogens was evaluated in uteri samples obtained during the proliferative and secretive phases of the menstrual cycle. The effects of binding by human serum proteins on estrogen influx into the endometrium and myometrium were also determined by the use of double-isotope, single-injection, timed tissue sampling techniques adapted to the extracorporeal perfusion of human uterus. Tritiated test estrogen was injected into the uterine artery as a mixture with 14C-butanol, a free diffusible reference substance. The influx of 14C-dextran (a membrane-impermeable compound) was used to test the aspecific influx from vasculature to extravascular space. Results show that in the human perfused uterus: (1) membrane permeability plays different roles in estrogen influxes between the endometrium and myometrium; (2) during the proliferative and secretive phase of the menstrual cycle the uterine microvessels are differently permeable to the free plus protein-bound estrogens; and (3) plasma proteins decrease the endometrial and myometrial uptakes of estrogens.

Basement membrane components in normal hyperplastic and neoplastic endometrium.

The major basement membrane (BM) components, laminin and type IV collagen, were studied by immunochemistry in normal, hyperplastic, and neoplastic endometrium. By immunoperoxidase technique, proliferative and secretive endometrium showed capillary and epithelial cell basement membranes with linear staining with antibodies to both laminin and type IV collagen. Immunostaining of laminin and type IV collagen showed that capillaries were surrounded by a continuous perivascular sheath of these matrices in specimens of adenomatous hyperplasia and in nearly all specimens of endometrial adenocarcinoma. Laminin and type IV collagen were found to accumulate around glandular epithelial cells of adenomatous hyperplastic endometrium, but in several specimens these linear surrounding formations were defective and discontinuous. In several areas of well-differentiated endometrial adenocarcinomas BM-like structures were found around glandular epithelial cells as shadows without staining for laminin and type IV collagen. These basement membrane components accumulate around stromal cells to encircle each cell with a gradual, progressive, and cyclic process depending on the phase of the menstrual cycle. Laminin and type IV collagen were clearly detected around stromal cells at days 20 to 22 of the menstrual cycle and more thickly at days 26 to 28. The accumulation of these matrices around stromal cells is a progesterone/progestin-related process. In the well-differentiated adenocarcinoma a mid-term treatment with progestin (Danatrol Maggioni-Winthrop, SPA, Milan, Italy) was found to be effective on laminin and type IV collagen accumulation around stromal cells.

Early human pregnancy in vitro utilizing an artificially perfused uterus.

The penetration of luminal epithelium in the uterine cavity represents the crucial event that triggers the failure of embryo implant, thus limiting the possibility of fertility control. The purpose of our study was to implant a human blastocyst, cultured in vitro, into a human uterus extracorporeally perfused with an oxygenated medium. For this purpose, human blastocysts, collected from patients who underwent IVF program because of irreparable tubal infertility, were injected under the luminal epithelium of human perfused uteri. Light and electron microscopy showed that human blastocyst can successfully undergo the stage of implantation and trophoblastic invasion in 52 hours of extracorporeal perfusion.

Increased extraction of estrogens in human endometrial hyperplasia and carcinoma.

The present study was undertaken to assess in vitro the endometrial extraction of natural estrogens. Normal, hyperplastic, and neoplastic endometria were studied. This was accomplished by the use of double isotope, single-injection techniques performed during the extracorporeal perfusion of human isolated uterus. The differential permeability of vascular beds in normal and neoplastic endometrium to estrogens was evaluated. The effects of binding by human serum proteins on estrogen influx into the endometrium were also determined. When protein-free Ringer's solution was used as an injection vehicle, both normal and abnormal endometrium permitted free diffusion of estradiol (E2), estrone (E1), and estrone sulfate (E1S). In contrast, the endometrial extraction of these estrogens from human female serum was significantly lower than that obtained with Ringer's solution. The extraction of E2, E1, and E1S from human serum was significantly higher in hyperplastic and carcinomatous endometria than in normal proliferative endometria. We conclude that 1) membrane permeability to estrogenic influxes differs between normal and abnormal endometria and 2) plasma proteins decrease the endometrial uptake of estrogens.

Danazol reverses endometrial hyperplasia to normal endometrium.

Danazol, an isoxazol derivate of ethinyltestosterone, was used in the treatment of thirtyone postmenopausal patients with endometrial hyperplasia at the dose of 400 mg/day for three months. A profound growth-inhibitory effect of danazol on human endometrium was previously suggested. The present study shows that this compound is effective to reverse the endometrial hyperplasia to normal endometrium in 97% of cases. Atrophic changes of endometrial hyperplasia to normal endometrium after danazol-treatment were observed in 68% of patients. These results strongly suggest that danazol has a significant antiproliferative effect on the endometrium.

A 48-hour preservation of an isolated human uterus: endometrial responses to sex steroids.

Human uteri were perfused with Krebs-Ringer bicarbonate-glucose buffer with and without estrogens and progesterone for a period of up to 48 hours to preserve a viable organ, which was responsive to hormones. Flow rates of 12 to 35 ml/minute per artery were fully distributed into the organ, with pressure values ranging from 80 to 120 mm Hg. Arteriovenous gradients of oxygen and carbon dioxide tensions as well as the levels of lactate, lactic dehydrogenase, and creatine kinase released in the perfusate, indicators of tissue ischemia or cell necrosis, showed a good preservation of the organ for up to 48 hours. The light- and electron-microscopic examinations of endometrial and myometrial tissues taken before and during perfusion confirmed this result. The extracorporeal perfusion of uteri with buffer containing estrogens plus progesterone exhibited secretive modifications of the proliferative endometrium, thus suggesting the viability of the organ and its responsiveness to sex steroids.

Changes in the uterine vasculature during the menstrual cycle.

The uterine vasculature of 15 uteri, which were hysterectomized for cervical cancer, has been studied. The removed uteri were immediately cannulated with four catheters inserted into the uterine arteries and veins and the vasculature was flushed with a saline-heparin solution. The vessels were clearly visualized by injection of radioopaque medium or of 5-10 ml prevulcanized natural latex, followed by tissue digestion. Histological studies of uterine specimens were also carried out for histomorphologic studies. The results show differences in the architecture of uterine vasculature, related to the cyclic hormonal changes. Most of the modifications occur in the radial and coiled arteries as well as in "venous lakes" of the endometrium.

A rare case of absence of vagina with the presence of functioning uterus: surgical treatment.

A rare case of absence of vagina in presence of a functioning uterus is reported. The surgical treatment--McIndoe's operation--has permitted to obtain an artificial vagina connected to the uterine cavity.