Effects of anodal TDCS stimulation of left parietal cortex on visual spatial attention tasks in men and women across menstrual cycle.

Sex hormonal variations have been shown to affect functional cerebral asymmetries in cognitive domains, contributing to sex-related differences in functional cerebral organization. The aim of this study was to investigate spatial attention by means of a bisection line test and computer-supported attention task during the menstrual cycle in healthy women compared to men, in basal condition and under Transcranial Direct Current Stimulation (TDCS) of the left parietal cortex. Women were studied during the menses, follicular and luteal phases, ascertained by transvaginal ultrasounds. In basal conditions, women showed a clear deviation toward the right in the bisection line test during the menstrual phase, similarly to men. The midpoint recognition in the computer-supported attention task was not influenced by the menstrual cycle for women, while men showed a significant increase in errors toward the left side. The anodal activation of the left parietal cortex did not affect the line bisection task, while in men it reduced the total amount of errors in midpoint recognition observed in the computer supported attention task. The hand-use effect demonstrated by the bisection-line test could be influenced by estrogen fluctuations, while the right hemisphere prevalence in spatial attention appears to be gender-related and scarcely influenced by the menstrual cycle. The left parietal cortex seems to exert a scarce effect on hand-use effect, while its activation is able to revert sex related right hemisphere supremacy.

Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography.

PURPOSE: This study assessed the diagnostic accuracy of pelvic magnetic resonance (MR) imaging completed by MR colonography for the preoperative evaluation of deep pelvic endometriosis in patients undergoing laparoscopic surgery. MATERIALS AND METHODS: A total of 143 patients (mean age 34.3 ± 5.1 years) with a clinical suspicion of deep pelvic endometriosis were assessed by pelvic MR and MR colonography. All patients underwent laparoscopic surgery 3-10 weeks after the MR examination. The presence, location, number and extent of endometriotic lesions were evaluated. Data obtained with MR were compared with surgical findings. MR sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy values were calculated for each site by considering the laparoscopic and histological findings as the reference standard. RESULTS: Laparoscopy confirmed the presence of endometriosis in 119/143 patients (83%); in 76/119 (64%) deep pelvic endometriosis was diagnosed, whereas in the remaining 43/119 (36%), superficial peritoneal implants and endometriomas were found. In 32/119 (27%) patients, intestinal lesions were detected. MR had sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 67-100%, 85-100%, 83-100%, 84-100% and 84-100%, respectively, in recognising lesions located in different pelvic sites. CONCLUSIONS: MR imaging combined with colonography is a highly accurate tool for characterising deep endometriotic lesions in patients scheduled for laparoscopic surgery. In particular, MR colonography has very high accuracy in detecting colorectal involvement.

Accuracy of transvaginal sonography and contrast-enhanced magnetic resonance-colonography for the presurgical staging of deep infiltrating endometriosis.

OBJECTIVE: To investigate the accuracy of transvaginal sonography (TVS) and contrast-enhanced magnetic resonance-colonography (CE-MR-C) for the presurgical assessment of deep infiltrating endometriosis (DIE). METHODS: Ninety women were enrolled prospectively for suspicion of DIE. All patients underwent TVS and CE-MR-C, with each operator blinded to the results of the other exam, before laparoscopy. The sites of DIE examined by both imaging techniques were: rectovaginal septum, pouch of Douglas, uterosacral ligaments, vesicouterine pouch, bowel, bladder and vagina. The presence of adhesions and the involvement of adnexa and of a previous abdominal scar, when there was clinical suspicion, were also evaluated. TVS and CE-MR-C findings were compared with laparoscopic and histological results. RESULTS: Endometriosis was confirmed by laparoscopy in 95.6% (86/90) of cases. In 82.2% (74/90) of patients there was DIE. The global accuracy for TVS in the detection of DIE was 89.2%, sensitivity was 81.1%, specificity was 94.2%, positive predictive value was 89.6%, negative predictive value was 89.0%, the positive likelihood ratio was 13.9 and the negative likelihood ratio was 0.2. For CE-MR-C, these values were 87.2%, 71.1%, 97.1%, 93.7%, 84.6%, 24.4 and 0.3, respectively. CE-MR-C allowed diagnosis of all cases of bowel involvement; the accuracy for infiltration and stenosis was 100%. The accuracy of TVS for rectosigmoid nodules was 91.1% and that for infiltration was 88.9%. CONCLUSIONS: Both TVS and CE-MR-C showed satisfactory results for the presurgical assessment of DIE. TVS appears to be a powerful, simple, feasible, cost-effective tool for preoperative staging of DIE. CE-MR-C is an 'X-ray free' technique, which could be reserved for cases with deep infiltrating rectosigmoid lesions and for the prediction of stenosis and involvement of the upper part of the colon and small intestine.

Surgical technique to avoid bladder flap formation during cesarean section.

Cesarean section (CS) is now the most common major surgical procedure performed on women worldwide. A CS can be performed by either suturing or not suturing of the visceral peritoneum. Creation of the bladder flap is an integral step of the standard cesarean section. The bladder flap is made by superficially incising and dissecting the peritoneal lining to separate the urinary bladder from the lower uterine segment. It's still debated whether the formation of bladder flap is advantageous or not. If the uterine incision is made slightly above the vesicouterine peritoneal fold, the loose connective tissue between the uterus and the urinary bladder allows spontaneous descent of the bladder. Evidence on the role of the bladder flap in cesarean section is very limited. At present, it remains to be established whether there is any advantage in dissecting the bladder from the lower uterine segment during cesarean section.

Prevention of adhesions in gynaecological endoscopy.

Adhesions resulting from gynaecological endoscopic procedures are a major clinical, social and economic concern, as they may result in pelvic pain, infertility, bowel obstruction and additional surgery to resolve such adhesion-related complications. Although the minimally invasive endoscopic approach has been shown to be less adhesiogenic than traditional surgery, at least with regard to selected procedures, it does not totally eliminate the problem. Consequently, many attempts have been made to further reduce adhesion formation and reformation following endoscopic procedures, and a wide variety of strategies, including surgical techniques, pharmacological agents and mechanical barriers have been advocated to address this issue. The present review clearly indicates that there is no single modality proven to be unequivocally effective in preventing post-operative adhesion formation either for laparoscopic or for hysteroscopic surgery. Furthermore, the available adhesion-reducing substances are rather expensive. Since excellent surgical technique alone seems insufficient, further research is needed on an adjunctive therapy for the prevention and/or reduction of adhesion formation following gynaecological endoscopic procedures.

Cervical squamous intraepithelial lesions of low-grade in HIV-infected women: recurrence, persistence, and progression, in treated and untreated women.

BACKGROUND: Human immunodeficiency virus (HIV)-infected patients are more predisposed than HIV-negative women to develop squamous intraepithelial lesions (SIL) of the uterine cervix, and cervical dysplasia may be of higher grade in HIV-positive women than in HIV-negative subjects, with more extensive and multi-centric involvement of the lower genital tract by human papillomavirus (HPV)-associated lesions. Moreover, recurrence and progression rate of cervical intraepithelial neoplasia (CIN) is particularly higher in immunocompromised women. DESIGN: Retrospective case-control study of HIV-positive women and HIV-negative controls, all affected by low-grade SIL of the uterine cervix, treated by loop excision or followed-up without treatment. Correlation of progression and recurrence of SIL with HIV status and CD4+ count. PATIENTS: From September 1990 to October 1997, 75 HIV-positive low-grade-SIL patients, 47 treated and 28 followed-up without treatment, and 75 HIV-negative low-grade-SIL controls, 45 treated and 30 followed-up. RESULTS: Among treated patients, 17/47 (36.2%) HIV-positive and 5/45 (11.1%) controls had recurrence (P < 0.0101, O.R. = 4.53, 95% CI = 1.5-13.7), progression of untreated lesion was seen in 15/28 (53.6%) HIV-positive and 7/30 (23%) controls (P < 0.05, O.R. = 3.79, 95% CI = 1.23-11.69). The risk of recurrence or progression of low-grade SIL linked to HIV seropositivity is about 4-5 times higher in comparison with seronegative counterpart, matched for age, risk factors and lesion size. More significantly, considering the cut-off of 200 CD4+/mm(3) in HIV-positive women, 13/17 cases of recurrence (P < 0.05, O.R. = 4.88, 95% CI = 1.28-18.58) and 10/15 cases with progression (P < 0.05, O.R. = 6.67, 95% CI = 1.24-35.73) were immunocompromised (<200 CD4+/mm3), with a significant higher risk of recurrence or progression linked to immunodeficiency status. Considering time of progression or recurrence, during follow-up, Kaplan-Meier curves shows that HIV-positive status and immunodeficiency are correlated with more rapid evolution of cervical dysplasia and HPV-related lesions: comparison of recurrence in treated patients report P < 0.005 and progression in untreated P<0.05 (Mantel-Haenszel log-rank test). CONCLUSIONS: Immunological status seems to be a determinant factor in prognosis of cervical SIL, HIV-positive women affected by this lesion, even if low-grade, need more aggressive management than the immunocompetent counterpart. Strict cytologic and colposcopic screening is recommended and CD4+ count and HPV-DNA testing may be useful risk indicators. Excisional procedures are preferred, while ablative treatments or wait and see policy may expose to some risk this type of population with poor compliance to follow-up.

Hormone replacement therapy on ovarian and uterine cancer risk and cancer survivors: how shall we do no harm?

This article will focus on the results of the Women's Health Initiative on the effects of hormone replacement therapy on coronary heart disease, stroke, venous thromboembolism, breast cancer, and colorectal cancer. Data from other relevant trials, including the most recent data on ovarian and uterine cancer risk and on gynecologic cancer patients, are also discussed to provide some guidelines on prescribing hormone replacement therapy in clinical practice, particularly in gynecologic cancer survivors.

Operative office hysteroscopy without anesthesia: analysis of 4863 cases performed with mechanical instruments.

STUDY OBJECTIVE: To evaluate the efficacy of, and patients' satisfaction with, office hysteroscopic treatment of benign intrauterine pathologies using 5F hysteroscopic instruments. DESIGN: Observational clinical study (Canadian Task Force classification II). SETTING: University center. PATIENTS: Four thousand eight hundred sixty-three (4863) women. INTERVENTION: Office hysteroscopy without analgesia or anesthesia. MEASUREMENTS AND MAIN RESULTS: We used 5F mechanical instruments (scissors, grasping forceps) to treat cervical and endometrial polyps ranging between 0.2 and 3.7 cm, as well as intrauterine adhesions and anatomic impediments. From 71.9% to 93.5% of women underwent the procedure without discomfort for all pathologies treated except endometrial polyps larger than the internal cervical os, for which 63.6% experienced low or moderate pain. At 3-month follow-up, pathology persisted in 364 patients (5.6%). CONCLUSION: Simple instruments enable us to perform many operative procedures in an office setting with excellent patient satisfaction, provided that the indications are correct.

Hysteroscopy does not increase the risk of microscopic extrauterine spread in endometrial carcinoma.

Fluid hysteroscopy has been suspected to cause tumor dissemination in the abdominal cavity in endometrial cancer patients. The aim of our study was to evaluate the incidence of microscopic extrauterine spread according to diagnostic modality (dilatation & curretage, D&C, hysteroscopy, or both) in patients with endometrial carcinoma. A retrospective study was conducted on 147 patients with histologically proven diagnosis of endometrial carcinoma without macroscopic extrauterine disease. Fluid hysteroscopy was performed by using saline solution irrigated at a final flow of 150 ml/min with a intrauterine pressure ranging between 25 and 50 mmHg. Microscopic intraperitoneal disease and positive peritoneal cytology were considered the primary end-points of this analysis. Fifty-two patients (35%) had diagnosis of endometrial cancer made only by D&C, 56 (39%) underwent D&C and then hysteroscopy, and 39 (26%) had only hysteroscopy. Distribution of the patients in this three groups was casual, and clinicopathologic characteristics of the patients in the three groups were similar. Peritoneal cytology was positive in nine patients, 13 had microscopic ovarian metastases, and eight had microscopic involvement of the pelvic peritoneum or of omentum. Neither the presence of positive peritoneal cytology nor the findings of microscopic intraperitoneal dissemination were significantly associated with the diagnostic procedure employed for primary diagnosis (D&C or D&C plus hysteroscopy or hysteroscopy alone). We conclude that fluid hysteroscopy does not increase the risk of microscopic intraperitoneal spread in endometrial cancer patients as compared to D&C.

Antimicrobial prophylaxis in laparoscopic gynecologic surgery: a prospective randomized study comparing amoxicillin-clavulanic acid with cefazolin.

Numerous studies have been published in recent years about antimicrobial prophylaxis in gynecologic surgery, but the optimal drug and schedule for the different surgical procedures is still a matter of debate. The aim of the present study was to compare two ultra-short term antimicrobial prophylaxis regimens (amoxicillin-clavulanic acid and cefazolin) in preventing infections following laparoscopic gynecologic operations. Three hundred sixty women hospitalized for a laparoscopic gynecologic surgery procedure were included in the study between January 1999, and December 2001. Patients were randomly allocated to receive amoxicillin-clavulanic acid (2.2 g) [Group A] or cefazolin (2 g) [Group B] as a single dose 30 minutes before surgery. Each patient was assessed daily until discharge to evidence febrile status and the presence of infections at the operative site, urinary tract and respiratory tract. In the amoxicillin-clavulanic acid (Group A) and cefazolin (Group B) groups, overall 164 and 172 patients, respectively, were evaluable for prophylactic efficacy at hospital discharge. Infectious complications were infrequent in both groups with febrile morbidity occurring in only one patient (0.6%) in the amoxicillin-clavulanic group. No sign of infections at the surgical site, urinary tract and respiratory tract was observed in either group. No death due to sepsis was recorded. It is concluded that ultra-short term prophylaxis with both amoxicillin-clavulanic acid and cefazolin is safe and effective in elective laparoscopic gynecologic surgery.

Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5 Fr. bipolar electrode.

BACKGROUND: The aim of this study was to evaluate treatment efficacy and patient acceptability of a new bipolar probe used during office hysteroscopic treatment of benign intrauterine pathologies. METHODS: In this observational clinical study, 501 women were treated for benign intrauterine pathologies using an office hysteroscopic procedure, without analgesia or anaesthesia. A Versapoint 5 Fr. bipolar electrical generator was used to treat endometrial polyps ranging between 0.5 and 4.5 cm, as well as submucosal and partially intramural myomas between 0.6 and 2.0 cm. Treatment efficacy and patient compliance were evaluated. RESULTS: At follow-up, the uterine cavity was normal in all patients without any recurrence or persistence of the pathology. One focal adenocarcinoma was discovered at histology in an endometrial polyp of a menopausal patient. Patient acceptance was satisfactory; 47.6-79.3% of the patients underwent the procedure without discomfort. CONCLUSIONS: The combination of a new generation small diameter hysteroscope and a new bipolar 5 Fr. electrode enables the gynaecologist to treat intrauterine pathologies in an office setting without anaesthesia. Experimentation of a special set-up of the electrical generator reduced patient discomfort during the operative part of the hysteroscopic procedure.

Endometrial biopsies using small-diameter hysteroscopes and 5F instruments: how can we obtain enough material for a correct histologic diagnosis?

STUDY OBJECTIVE: To evaluate the quantity of biopsy tissue obtained by hysteroscopic grasp technique compared with classic punch technique. DESIGN: Observational study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: One thousand two hundred seventy-six women. INTERVENTION: Targeted biopsies performed in an office setting using two biopsy forceps, classic spoon and crocodile, and two methods, classic punch and grasp technique. MEASUREMENTS AND MAIN RESULTS: With either biopsy forceps, the mean increase in amount of tissue obtained by grasp technique compared with punch technique was statistically significant (p <0.005). With grasp technique, the mean amount of tissue obtained was even larger with crocodile than with spoon forceps. CONCLUSION: Targeted biopsy, when performed with the appropriate instrument and applying correct technique, can provide the pathologist with a large amount of tissue (mean 5.7 mm2) that is invariably adequate for histologic examination.

Vertical transmission of hepatitis C virus in a cohort of 2,447 HIV-seronegative pregnant women: a 24-month prospective study.

BACKGROUND: Mother to infant transmission of hepatitis C virus (HCV) has been extensively studied in mothers with human immunodeficiency virus (HIV) infection, whereas fewer data are available on the vertical HCV transmission in HIV-negative women. METHODS: Between January 1995 and June 1997, 78 consecutive HCV-positive/HIV-negative women with their offspring entered this prospective study aimed to define the prevalence of and risk factors for HCV vertical transmission. Risk factors for HCV were carefully sought, and HCV viral load and genotype were determined in all positive mothers. The infants were tested for alanine aminotransferase (ALT) and HCV-RNA at birth and at 4, 8, 12, 18, and 24 months of age. RESULTS: Eight of 60 (13.3%) infants born to HCV-RNA positive mothers acquired HCV infection, but only 2 (3,3%) were still infected by the end of follow-up. Infants' genotypes matched that of the mothers. ALT levels were in the normal range in all study subjects throughout the follow-up. High maternal viral load (P < 0.05), possession of HCV risk factors (P < 0.004), and history of blood transfusion (P < 0.05) were associated with increased risk of HCV vertical transmission. CONCLUSIONS: This long-term prospective study shows that, although vertical transmission from HIV-negative mothers occurs in 13% of cases, there is a high rate of spontaneous viral clearance (75%). High maternal viral load and mothers belonging to HCV risk categories were the only variables predictive of the vertical transmission.

Diagnostic inadequacy of dilatation and curettage.

OBJECTIVE: To assess the diagnostic inadequacy of dilatation and curettage (D&C) by comparing histologic findings with this technique with those obtained after hysterectomy. DESIGN: Retrospective clinical study. SETTING: University-affiliated hospital. PATIENT(S): Three hundred ninety-seven patients with abnormal uterine bleeding who underwent D&C and, within 2 months, hysterectomy because of histologic findings or persistence of symptoms. MAIN OUTCOME MEASURE(S): Comparison of histologic findings on D&C with those obtained after hysterectomy. RESULT(S): In 248 of 397 patients (62.5%), D&C failed to detect intrauterine disorders subsequently found at hysterectomy; the sensitivity was 46%, the specificity was 100.0%, the positive predictive value was 100.0%, and the negative predictive value was 7.1%. CONCLUSION(S): Dilatation and curettage is an inadequate diagnostic and therapeutic tool for all uterine disorders; this technique missed 62.5% of major intrauterine disorders, and all endometrial disorders were still present in the removed uterus.

Legionnaire's disease complicating pregnancy: a case report with intrauterine fetal demise.

OBJECTIVE: Legionnaire's disease complicating pregnancy is an unusual event that can seriously compromise both the mother and the fetus. CASE REPORT: We describe one case of such association, with an unfavourable intrauterine fetal outcome, secondary to acute placental insufficiency, related to infection. DISCUSSION: It is important in these high risk pregnancies complicated by acute pneumonia to take into consideration the diagnosis, as early as possible, and the appropriate treatment or the careful monitoring of fetal wellbeing.

Hysteroscopic evaluation of the endometrium in postmenopausal women taking tamoxifen.

STUDY OBJECTIVE: To evaluate hysteroscopic endometrial changes due to tamoxifen therapy in postmenopausal women with breast cancer. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. Eighty-eight postmenopausal women (or with iatrogenic amenorrhea) receiving tamoxifen 20 mg/day for at least 1 year for breast cancer. INTERVENTION: Record review of patients undergoing transvaginal sonography (TVS) and office hysteroscopy with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow, operative hysteroscope. MEASUREMENTS AND MAIN RESULTS: Patients with thickened endometrium and pathologic findings at hysteroscopy had taken tamoxifen for significantly longer times than those without such findings (p < 0.05). CONCLUSION: Our findings confirm the estrogenic effect of tamoxifen on endometrium. Endometrial evaluation by TVS suggests further diagnostic procedures, but only hysteroscopy allows the surgeon to visualize endometrial lesions and obtain eye-directed biopsy tissue.