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Background: Sport practice may elevate the risk of cardiovascular events, including sudden cardiac death, in athletes with undiagnosed heart conditions. In Italy, pre-participation screening includes a resting ECG and either the Harvard Step Test (HST) or maximal exercise testing (MET), but the relative efficacy of the latter two tests for detecting arrhythmias and heart conditions remains unclear., Methods: This study examined 511 paediatric athletes (8-18 years, 76.3% male) without known cardiovascular, renal, or endocrine diseases. All athletes underwent both HST and MET within 30 days. Absolute data and data relative to theoretical peak heart rates, arrhythmias (supraventricular and ventricular) and cardiovascular diagnoses were collected., Results: HST resulted in a lower peak heart rate than MET (181.1 ± 9.8 vs. 187.5 ± 8.1 bpm, p < 0.001), but led to the detection of more supraventricular (18.6% vs. 13.1%, p < 0.001) and ventricular (30.5% vs. 22.7%, p < 0.001) arrhythmias, clustering during recovery ( p = 0.014). This pattern was significant in males but not females. Among athletes diagnosed with cardiovascular diseases (22.3%), HST identified more ventricular arrhythmias (26.3% vs. 18.4%, p = 0.05), recovery-phase arrhythmias (20.2% vs. 14.0%, p = 0.035), and polymorphic arrhythmias (6.1% vs. 1.8%, p = 0.025)., Conclusions: HST detects arrhythmias more effectively than MET in young male athletes, especially during recovery. More ventricular arrhythmias were highlighted even in athletes with cardiovascular conditions.

Background : The COVID-19 pandemic has strongly impacted on healthcare services' organization and healthcare workers' mental health, increasing the risk of psychological symptoms and burnout. Italy has been one of the most affected countries, especially the northern regions, even with exceptions in some rural provinces. Aim : We chose to investigate the mental health conditions of healthcare workers operating in the rural province of Rovigo (a small town in Veneto, northern Italy), where relatively few deaths and contagions were reported during the pandemic, even if Veneto-globally-was one of the most affected regions of Italy. We wanted to verify the psychological outcomes of health workers operating in a context where the impact of the pandemic appeared to be relatively mild. Methods : Through an online survey, we investigated perceived difficulties at work and in daily life, perceived loneliness and social support, coping strategies, and level of psychological distress (sample size: 749; mean age = 48.04 years, SD = 10.66). The questionnaire had both open- (2) and close-ended questions (5 single-choice and 13 multiple-choice). We verified possible associations between sex, age group, work department and percentage of responses with chi-square tests of independence on each question. Data cleaning excluded all contradictory answers from the multiple-choice questions from the analyses (final sample size: 640). Results : Frontliners and non-frontliners reported a similar experience of the COVID-19 pandemic (without significant differences in perceived difficulties, coping strategies and sources of support). Nevertheless, they still reported various forms of negative emotions (e.g., helplessness-40.94%; sadness-36.56%; frustration-32.66%) and lack of support from the health organization (especially frontliners-28.72%). However, psychological help was scarcely requested. Conclusions : Despite the province not being massively affected by the pandemic, healthcare workers felt the need for clearer and more supportive guidance. They seem to perceive collective opportunities to share needs and difficulties as more useful than individual interventions (as those provided by the ad hoc created listening service).

Aim: An online survey was proposed to the health workers of a public hospital of an Italian northern city. This was done with the aim of assessing the unmet needs of a special population under strain (the health carers) due to the fight against the coronavirus disease 19 (COVID-19). Results: By answering the survey, five hundred and nine people provided their observations, complaints and suggestions. This qualitative material was organised into three main areas: (1) relationship with the health organization management; (2) needs of the health workers; and (3) perceived consequences of the pandemic. Discussion: Overall, respondents expressed dissatisfaction for the unpreparedness of their health units and the confusion created by frequent changes in operational guidelines. Many participants felt abandoned, unheard and unprotected by the health organization, whilst the psychological support service formally set up by the hospital for its health workers was grossly under-utilised. Instead, support from colleagues and family constituted the main protective factor to counteract negative emotions. Restrictions in social contacts and recreational opportunities were frequently mentioned. Several respondents reported a sense of pride for their work and commitment; many others saw in the pandemic an opportunity for personal growth and better focus on important life values, like family and solidarity.

A survey about opinions on end-of-life issues of a population represented by 1,171 people in the waiting room of general practitioners' surgeries was conducted in a province of northern Italy. Most subjects did not consider suicide as a reasonable option even in cases of a serious and incurable disease. Moreover, subjects did not consider euthanasia as a possible option either; however, they did express an opposite attitude when considering euthanasia in a third-person perspective. People with a personal history of suicidal behavior appear to present as a different population, overall expressing more open attitudes., (© 2014 The American Association of Suicidology.)

Objectives: To retrospectively evaluate the impact on daily activities of transcatheter closure of patent foramen ovale (PFO) versus medical therapy in patients with migraine and to analyze the role of the residual shunt after PFO closure., Background: While non-controlled observational studies reported an improvement of migraine after PFO closure, a randomized trial has shown no benefit of such an intervention. The role of residual shunt after PFO closure is also poorly known., Methods: Out of 217 patients with migraine and echocardiographic evidence of PFO, 89 were managed with percutaneous PFO closure (Group A) while 128 were medically treated (Group B). All MIDAS questionnaires were obtained at the first evaluation and repeated at least 6 months after the index evaluation or after the PFO closure. All the patients were also asked to give a subjective estimate of their migraine status. A postprocedural transcranial Doppler study was available in 70 patients in Group A., Results: The mean basal MIDAS score did not differ between the two groups (p = 0.859). After a mean follow-up (FU) of 1399 ± 982 days the MIDAS score decreased significantly in both groups (Group A baseline vs FU, p < 0.001; Group B baseline vs FU, p < 0.001), but no differences were observed between groups (p = 0.204). However a significantly higher number of Group A patients reported a perceived clinical benefit or the disappearance of migraine compared to Group B (p < 0.001). Patients with moderate or severe residual right to left shunt were no more likely to have an higher MIDAS score or to complain of migraine than those with mild or no shunt., Conclusions: Although the overall evolution of migraine is not significantly different, the abolition of migraine occurs in a larger proportion after PFO closure., (Copyright © 2014. Published by Elsevier Ltd.)

A survey about history of non-fatal suicidal behaviour was performed on 1,171 subjects in the waiting room of general practitioners' practices in the territory of Rovigo (Northern Italy). The mean age of interviewed subjects was 52.9 ± 17.0, with a majority of female individuals. Two and two percent admitted previous experience of non-suicidal self-injury, 4.7 % admitted having had serious suicidal thoughts/plans, and 1.8 % reported at least one suicide attempt. Compared to the rest of the sample, people with history of suicidal behaviours resulted to be of younger age (p < .05), whilst their level of well-being was poorer (p < .001). When compared to the results of the Italian arm of the European Study of the Epidemiology of Mental Disorders, carried out on general population samples, the present study produces higher rates of suicidality, despite the much higher mean age of the interviewed subjects compared to the general population.

To evaluate whether botulinum toxin type A at standard doses spreads to antagonist leg muscles in dynamic equinus foot, we studied 18 ambulatory children with hemiplegic cerebral palsy. The gastrocnemius muscle on the affected side was injected with botulinum toxin type A (Dysport) (mean ± standard deviation, 14.3 ± 0.9 U/kg). Compound muscle action potential areas were assessed in the lateral gastrocnemius and tibialis anterior muscles on the treated and untreated sides before botulinum toxin type A injections and on days 10 and 30 after injections. In all patients, compound muscle action potential areas recorded from both the muscles on the treated side decreased from preinjection values at day 10 (P < .05) and 30 (P < .002). After injection, ankle spasticity had diminished (P < .05), equinus foot excursion increased (P < .05), and functional gait improved (P < .05). This study shows that botulinum toxin type A spreads from foot flexors to antagonist extensors and suggests that spread may be partly responsible for improving gait in children with cerebral palsy.

Objective: To investigate whether botulinum neurotoxin type A improves vaginismus and study its efficacy with repeated treatments., Methods: Outpatients were referred because standard cognitive-behavioral and medical treatment for vaginismus and vulvar vestibular syndrome failed. From this group, we prospectively recruited consecutive women (n=39) whose diagnostic electromyogram (EMG) recordings from the levator ani muscle showed hyperactivity at rest and reduced inhibition during straining. These women were followed for a mean (+/-standard deviation) of 105 (+/-50) weeks. Recruited patients underwent repeated cycles of botulinum neurotoxin type A injected into the levator ani under EMG guidance and EMG monitoring thereafter. At enrollment and 4 weeks after each cycle, women were asked about sexual intercourse; underwent EMG evaluation and examinations to grade vaginal resistance according to Lamont; and completed a visual analog scale (VAS) for pain, the Female Sexual Function Index Scale, a quality-of-life questionnaire (Short-Form 12 Health Survey), and bowel and bladder symptom assessment., Results: At 4 weeks after the first botulinum neurotoxin type A cycle, the primary outcome measures (the possibility of having sexual intercourse, and levator ani EMG hyperactivity) both improved, as did the secondary outcomes, Lamont scores, VAS, Female Sexual Function Index Scales, Short-Form 12 Health Survey, and bowel-bladder symptoms. These benefits persisted through later cycles. When follow-up ended, 63.2% of the patients completely recovered from vaginismus and vulvar vestibular syndrome, 15.4% still needed reinjections (censored), and 15.4% had dropped out., Conclusion: Botulinum neurotoxin type A is an effective treatment option for vaginismus secondary to vulvar vestibular syndrome refractory to standard cognitive-behavioral and medical management. After patients received botulinum neurotoxin type A, their sexual activity improved and reinjections provided sustained benefits., Level of Evidence: III.

Objective: To investigate possible altered CNS excitability in vaginismus., Methods: In 10 patients with primary idiopathic lifelong vaginismus, 10 with vulvar vestibulitis syndrome accompanied by vaginismus and healthy controls we recorded EMG activity from the levator ani (LA) and external anal sphincter (EAS) muscles and tested bulbocavernosus reflex (BCR). Pudendal-nerve somatosensory evoked potentials (SEPs) were tested after a single stimulus. Pudendal-nerve SEP recovery functions were assessed using a paired conditioning-test paradigm at interstimulus intervals (ISIs) of 5, 20 and 40ms., Results: EMG in patients showed muscular hyperactivity at rest and reduced inhibition during straining. The BCR polysynaptic R2 had larger amplitude (p<0.01) and longer duration (p<0.01) in patients from both groups than in controls. In controls, paired-pulse SEPs were suppressed at the 5ms ISI for N35-P40 (p<0.05) and P40-N50 ms (p<0.001) and facilitated at the 20ms ISI for N35-P40 (p<0.05) and P40-N50 (p<0.05). No significant differences were found in the paired-pulse N35-P40 in patients and controls but the cortical P40-N50 at 20 ISI was facilitated in patients (p<0.05)., Conclusions: EMG activity is enhanced and the cortical SEP recovery cycle and BCR are hyperexcitable in vaginismus., Significance: The neurophysiological abnormalities in patients with vaginismus indicate concomitant CNS changes in this disorder.

Our purpose was to test the effect of botulinum toxin injections on hypertonic pelvic floor muscles of patients suffering from genital pain syndromes. We report two cases of women complaining of a genital pain syndrome resistant to pharmacological therapies and rehabilitation exercises associated with a documented involuntary tonic contraction of the levator ani muscle as a defense reaction triggered by vulvar pain. We performed botulinum toxin injections into the levator ani with the intent to relieve pelvic muscular spasms. Within a few days after the injections both the patients reported a complete resolution of the painful symptomatology, lasting for several months. Our experience suggests that botulinum injections are indicated in patients with genital pain syndrome with documented pelvic muscle hyperactivity, whose symptoms arise not only from genital inflammation and lesions, but also, and sometimes chiefly, from levator ani myalgia., (Copyright (c) 2004 S. Karger AG, Basel.)

Objective: To ascertain whether adjuvant gonadotropin-releasing hormone (GnRH) agonist therapy decreases blood loss during abdominal myomectomy., Design: Randomized controlled trial., Setting: Academic reproductive surgery center., Patient(s): One hundred premenopausal women requiring first-line conservative surgery for symptomatic intramural or subserous fibroids., Intervention(s): Eight weeks of treatment with depot triptorelin before myomectomy or immediate surgery., Main Outcome Measures: Intraoperative blood loss, operating time, degree of difficulty of the procedure, and short-term rate of fibroid recurrence., Result(s): Mean (+/-SD) intraoperative blood loss was 265 +/- 181 mL in triptorelin recipients and 296 +/- 204 in patients who had immediate surgery (mean difference, -31 mL [95% CI, -108 to 46 mL]). No significant differences were observed in blood loss according to uterine volume, number of fibroids removed, or total length of myometrial incisions. Most procedures in either group were of routine difficulty. On ultrasonography 6 months after myomectomy, four women in the GnRH agonist group and one in the immediate surgery group had tumor recurrence., Conclusion(s): Treatment with a GnRH agonist before abdominal myomectomy has no significant effect on intraoperative blood loss. Thus, systematic use of medical therapy before abdominal myomectomy does not seem to be justified.

Objective: To investigate cortical excitability in patients with corticobasal degeneration (CBD) and to find a reliable diagnostic technique for differentiating CBD from Parkinson's disease (PD)., Methods: Using a paired transcranial magnetic stimulation technique, we studied motor cortex excitability at rest in 6 patients with clinically probable CBD, 10 patients with PD, and 10 normal subjects. The recovery cycle of the motor evoked potentials was tested by delivering paired magnetic stimulation over the hand area of the motor cortex at interstimulus intervals (ISIs) from 1 to 17ms., Results: In patients with CBD, paired magnetic stimuli delivered at short ISIs invariably elicited enlarged test MEPs. At ISIs of 1-10ms, the conditioned test MEPs were significantly larger in patients with CBD than in control subjects; and at ISIs of 1, 2, 4, and 6ms,they were also larger in patients with CBD than in patients with PD. At the other ISIs tested, patients and control subjects had similar amplitude conditioned test responses., Conclusions: Our findings suggest that the unusual clinical manifestations of CBD might arise partly from motor cortex disinhibition. Paired magnetic stimulation could be a useful diagnostic test particularly in the early stages of the disease.

Objective: To evaluate the efficacy and safety of cyproterone acetate versus an oral contraceptive in the treatment of endometriosis-associated recurrent pelvic pain., Design: Randomized controlled trial., Setting: Academic center., Patient(s): Ninety women with recurrent moderate or severe pelvic pain after conservative surgery for symptomatic endometriosis., Intervention(s): Six months of continuous treatment with oral cyproterone acetate, 12.5 mg/d, or an oral contraceptive containing ethinyl estradiol, 0.02 mg, and desogestrel, 0.15 mg., Main Outcome Measure(s): Degree of satisfaction with therapy., Result(s): Six patients in the cyproterone acetate arm and nine in the oral contraceptive arm withdrew because of side effects (n = 9), treatment inefficacy (n = 4), or loss to follow-up (n = 2). At 6 months, dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain scores were substantially reduced, and significant improvements were observed in health-related quality-of-life, psychiatric profile, and sexual satisfaction; no major between-group differences were seen. Subjective and metabolic side effects were limited. According to an intention-to-treat analysis, 33 of 45 (73%) of patients in the cyproterone acetate group and 30 of 45 (67%) in the oral contraceptive group were satisfied with the treatment received., Conclusions: Both cyproterone acetate and a continuous monophasic oral contraceptive were effective, safe, and inexpensive therapy for recurrent pain after conservative surgery for endometriosis.

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.

Objective: To determine whether the depth and volume of the pouch of Douglas differs in patients with endometriosis with and without deep lesions and to compare them with subjects with a healthy pelvis or with diseases other than endometriosis., Design: Prospective, comparative study., Setting: Tertiary care and referral center for patients with endometriosis., Patient(s): Women undergoing laparoscopy for infertility, pelvic pain, or adnexal anomalies (deep endometriotic rectovaginal lesions in 16 cases, endometriosis without deep lesions in 127 cases, miscellaneous anomalies in 35 cases, and normal pelvis in 26 cases)., Intervention(s): Douglas pouch depth measurement from the upper border of uterosacral ligaments to its base with a calibrated probe and volume assessment by a fluid-filling technique., Main Outcome Measure(s): Douglas pouch depth and volume., Result(s): Mean (+/-SD) Douglas pouch depth and volume measurements were 3.6 +/- 1.6 cm and 41.6 +/- 19.3 mL in women with deep endometriosis, 5.3 +/- 0.8 cm and 67.2 +/- 18.1 mL in those with peritoneal and ovarian lesions only, 5.2 +/- 0.9 cm and 67.6 +/- 12.6 mL in those with miscellaneous conditions, and 5.5 +/- 0.8 cm and 65.8 +/- 10.9 mL in those with normal pelvis., Conclusion(s): Reduced Douglas pouch depth and volume in women with deep endometriosis suggest that such lesions develop not in the rectovaginal septum but intraperitoneally and that burial by anterior rectal wall adhesions creates a false bottom, giving an erroneous impression of extraperitoneal origin.

Six cases of endometriosis obstructing the left ureter were observed among 1,054 consecutive patients undergoing surgery in an eight-year period. In addition, 125 women with ureteral endometriosis (left-sided, n = 66; right-sided, n = 40; bilateral, n = 19) were described in 62 articles identified in a systematic review of the English language literature between 1980 and 1998. Considering only the patients with unilateral ureteral endometriosis and combining the published figures with those of our surgical series, the observed proportion of left lesions (72/112, 64%; 95% CI 55% to 73%) was significantly different from the expected proportion of 50% (chi2(1), 9.14, P = 0.002). The lateral asymmetry found in the location of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomical differences of the left and right hemipelvis.

To investigate the left- and right-sided distribution of nonendometriotic benign ovarian cysts, data were collected on 406 women undergoing first-line surgery for tumours with various histotypes. Considering the unilateral cysts, the observed proportion of left lesions was 65/129 (50.4%) in the serous, 38/79 (48.1%) in the mucinous, 59/134 (44.0%) in the dermoid, 11/21 (52.4%) in the parovarian, and 3/7 (42.9%) in the miscellaneous cysts group, without significant differences from the expected 50%. This contrasts with the finding of a significantly more frequent development of endometriomas on the left ovary, and suggests that the pathogenesis of endometriotic and nonendometriotic cysts is different.

In this study we sought to determine whether a natural condition involving fine discrimination, for example moderately severe myopia, might yield interesting information regarding the binocular interaction expressed by visual evoked potentials (VEPs). We studied ten normal subjects with a mild refraction deficits. Transient VEPs were elicited by monocular and binocular stimulation under conditions of natural and lens-corrected vision. The visual stimulus was a pattern-reversal checkerboard consisting of 15' and 40' checks. VEPs in response to binocular stimulation were compared with monocular VEPs. We plotted the monocular 'better-VEP' and 'worse-VEP' response, since significant differences between individual eye stimulations were present. We found no significant difference between the mean N75 and P100 latencies of the binocular VEP and the better monocular VEP, regardless of the check size used and of natural or corrected vision. Under all stimulus conditions, the mean amplitude of the N75-P100 of the binocular VEPs was also larger than the better monocular VEP response. The difference proved more significant when we stimulated our subjects with smaller squares and left vision uncorrected. The mean P100-N145 amplitude obtained with binocular stimulation was larger than the better monocular VEP response only when using small checks (15') and uncorrected vision. Overlapping latencies are consistent with an earlier hypothesis that monocular and binocular VEPs originate postsynaptically from the binocular neurons in the primary visual cortex. The gain in amplitude achieved by binocular stimulation may depend upon the removal of 'tonic interocular inhibition' and/or on a cortical modulatory mechanism.