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To evaluate the feasibility of a bilateral multiple ovarian biopsy through minilaparoscopy under local anesthesia and conscious sedation and to assess the efficacy of this technique as compared to the traditional laparoscopic approach.Twenty-five infertile women with premature ovarian failure underwent bilateral ovarian biopsy plus chromoperturbation. Twelve patients were treated with minilaparoscopy (minilap group) and preoperatively received mepivacaine for subcutaneous local anesthesia and midazolam plus fentanyl for conscious sedation. Following minilaparoscopy, 40 mL of 0.5% intraperitoneal subdiaphragmatic lidocaine and 5 mL of ropivacaine, 7.5 mg/mL, for infiltration of the trocar insertion sites were administered. Thirteen women (control group) were treated with the traditional laparoscopic approach under general anesthesia. If necessary, ketoprofene or intramuscular ketorolac was administered following surgery. Postoperative pain score was evaluated by a 1-10 visual analogic scale immediately after surgery and in the following 24 hours; in addition, the quantity of ovarian biopsy material for the pathologist and the discharge and operative times were evaluated.The minilap group had lower postoperative pain scores postoperatively. Operative time was similar in both groups. The rate of discharge two hours after surgery was significantly higher in the minilap group. In all cases the amount of ovarian tissue was sufficient for diagnosis. Twenty-one patients were affected by premature menopause and four by resistant ovary syndrome. The need for postoperative analgesics was significantly higher in the control group.Minilap allows the performance of bilateral, multiple ovarian biopsy under local anesthesia and conscious sedation in association with chromoperturbation and the obtaining a sufficient amount of ovarian tissue for histopathologic diagnosis. Intraperitoneal lidocaine administration and ropivacaine infiltration of the trocar sites were beneficial for patients undergoing operative minilap in a day-surgery setting. The effect of these drugs was obviously temporary; however, low postoperative pain scores and low additional analgesic requirement permitted early discharge, within two hours after surgery.

To investigate the therapeutic effectiveness in infertile couples with anovulatory, mild endometriosis-related and unexplained infertility of a personalized approach to controlled ovarian hyperstimulation (COH) (group A) on the basis of body mass index (BMI) and waist/hip ratio (WHR) in comparison to a conventional protocol (group B).In group A, we obtained a significantly higher pregnancy rate and number of multifollicular cycles in comparison to group B. In addition, the pregnancy rate/ovulatory cycle and the number of ovulatory cycles were higher (but not significantly) in group A. In group B, we observed a not significantly higher number of monofollicular cycles and required length of stimulation in comparison to group A.A personalized therapeutic protocol, based on simple criteria such as BMI and WHR, leads to a higher number of single and twin pregnancies, without any significant increase of higher grade multiple pregnancies or severe ovarian hyperstimulation syndrome.

To evaluate the feasibility of ovarian drilling using minilaparoscopy under local anesthesia and to determine its efficacy in the surgical treatment of polycystic ovarian syndrome.Prospective randomized study carried out in an out patient service on 62 women affected by PCOS divided into two groups: 32 patients (group A) underwent bilateral ovarian drilling by minilaparoscopy under local anesthesia and 30 patients (group B) underwent bilateral ovarian drilling by traditional laparoscopy under general anesthesia.Operation times were not different between the two groups. Discharge time was significantly lower in group A in comparison to group B. The rate of patients discharged after 2 hours was significantly higher in group A. The need for additional analgesia was lower in group A in comparison to group B. Serum LH, A and T levels were significantly reduced after surgery in both groups. Pregnancy rate after 1-year follow-up was higher, although not significantly in group A. Ovulation and abortion rates were not different between the two groups.Ovarian drilling in minilaparoscopy under local anesthesia is a new option for gynecologists, allowing similar therapeutical results to those achieved by traditional laparoscopy, but with the benefits of a less invasive technique that can be carried out in an outpatient service without the need for general anesthesia.

To compare the efficacy of two modalities of local anesthesia for diagnostic hysteroscopy in different steps of the procedure in terms of pain control and time required for the examination.One hundred eighty women undergoing diagnostic hysteroscopy were included in the study and randomly allocated to one of two groups. Group A (n = 88), treated with prilocaine plus lidocaine cream, and group B (n = 92), treated with lidocaine spray, were compared with group C, a control group (n = 165), including all the hysteroscopies performed without anesthesia in the same period. Duration of the hysteroscopic examination was recorded; intensity of pain induced by the procedure and shoulder pain 10 minutes after the end of the examination were recorded for all patients on the basis of a four-point pain scale.Duration of the procedure required was two minutes in a significantly lower percentage of patients in group A as compared to groups B and C. Furthermore, in group A we found a significant reduction in pain at placement of the tenaculum in comparison to groups B and C. In groups A and B, no patient experienced a "very painful" grade of pain versus 4.8% in group C. The vasovagal reaction rate was also significantly lower in both treated groups in comparison to the control group. Furthermore, the intensity of shoulder pain was significantly lower in the group receiving prilocaine plus lidocaine cream as compared to the other two groups.Local anesthesia has a beneficial effect, at least in those hysteroscopies presumed to be, for whatever reasons, more cumbersome to perform. Prilocaine plus lidocaine cream was more effective than lidocaine spray in decreasing pain at placement of the tenaculum and shoulder pain after the procedure.

Introduction Several studies have assessed the histological co-existence of endometrial carcinoma (EC) and adenomyosis. However, the significance of this association is still unclear. Objective To assess the prevalence of adenomyosis in women with EC for a better understanding of the association between the two diseases. Materials and methods A systematic review and meta-analysis was performed by searching electronics databases from their inception to March 2020, for all studies that allowed extraction of data about prevalence of adenomyosis in EC patients. Adenomyosis prevalence was calculated for each included study and as pooled estimate, with 95% confidence interval (CI). Results Eight retrospective cohort studies assessing 5573 EC patients were included in our analysis. Of total, 1322 were patients with adenomyosis, and 4251 were patients without adenomyosis. Pooled prevalence of adenomyosis in EC patients was 22.6% (95% CI 12.7–37.1%). Conclusion Adenomyosis prevalence in EC patients was not different from that reported for other gynecological conditions. The supposed association between the two diseases appears unsupported.

Objective: To evaluate fetal fibronectin as a screening test for premature delivery in asymptomatic women with multiple pregnancies. Method: In the mid-second trimester, the concentrations of fetal fibronectin in the cervical and vaginal secretions of 68 patients with multiple gestations were sampled weekly by monoclonal antibody immunoassay in order to predict preterm labor. Results: The results for the prediction of preterm labor differ according to whether we consider a single positive result (fetal fibronectin >50 ng/ml) as predictive of preterm labor or whether we only consider at least two consecutive positive results as predictive of preterm labor. The fetal fibronectin test had a sensitivity for preterm birth before 37 weeks of 90.9% and 86.6%, respectively, with a specificity of 68.5% vs. 78.9% and positive and negative values of 73.1% vs. 76.4% and 88.8% vs. 88.2%, respectively. Similar results were obtained for preterm birth before 34 weeks. Conclusion: In a condition such as multiple pregnancy which is already at risk for premature delivery the possibility of raising the specificity of the test with virtually no decrease in sensitivity guarantees better recognition of patients likely to develop premature labor. This possibility can be achieved simply by considering two positive consecutive samples as predictive of preterm labor.

Background: During fractional flow reserve (FFR) measurement, the simple presence of the guiding catheter (GC) within the coronary ostium might create artificial ostial stenosis, affecting the hyperemic flow. We aimed to investigate whether selective GC engagement of the coronary ostium might impede hyperemic flow, and therefore impact FFR measurements and related clinical decision-making. Methods: In the DISENGAGE (Determination of Fractional Flow Reserve in Intermediate Coronary Stenosis With Guiding Catheter Disengagement) registry, FFR was prospectively measured twice (with GC engaged [FFR eng ] and disengaged [FFR dis ]) in 202 intermediate stenoses of 173 patients. We assessed (1) whether ΔFFR eng –FFR dis was significantly different from the intrinsic variability of repeated FFR measurements (test-retest repeatability); (2) whether the extent of ΔFFR eng –FFR dis could be clinically significant and therefore able to impact clinical decision-making; and (3) whether ΔFFR eng –FFR dis related to the stenosis location, that is, proximal and middle versus distal coronary segments. Results: Overall, FFR significantly changed after GC disengagement: FFR eng 0.84±0.08 versus FFR dis 0.80±0.09, P eng –FFR dis , proximal and middle 0.04±0.03 versus distal segments 0.03±0.03; P =0.042). Conclusions: GC disengagement results in a shift of FFR values from above to below the clinical cutoff FFR value of 0.80 in 1 out of 5 measurements. This occurs mostly when the stenosis is located in proximal and middle coronary segments and the FFR value is close to the cutoff value.

Objectives: To define the impact of side branch (SB) lesion length on clinical outcomes after percutaneous coronary intervention (PCI) on bifurcation lesions. Background: The role of the SB lesion length remains questionable in PCI planning and its implication on clinical outcome is controversial. Methods: Data from the retrospective multicenter EBC-P2BiTO registry were analyzed. The primary endpoint was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction excluding periprocedural, or stent thrombosis at 13 months median follow-up (IQR 11-28). By using propensity scores for inverse probability of treatment weighting (IPTW), the comparison of treatment groups was adjusted to correct for potential confounding. Results: Among 1, 252 patients, SB was normal in 489 (39%), diseased in 763 (61%) cases. MACE occurred in 68 patients (5.4%). The optimal discriminant SB lesion length for MACE was ≥10 mm, with an area under the curve of 0.71 (p < .01). The incidence of MACE was higher among patients with SB lesions ≥10 mm (8%) than with normal SB (4.1%) (hazard ratio [HR], 2.8 ; 95% confidence interval [CI], 1.5-5.3 ; p = .001, IPTW-adjusted) or SB lesions

Aims Significant platelet activation after long stented coronary segments has been associated with periprocedural microvascular impairment and myonecrosis. In long lesions treated either with an everolimus-eluting bioresorbable vascular scaffold (BVS) or an everolimus-eluting stent (EES), we aimed to investigate (a) procedure-related microvascular impairment, and (b) the relationship of platelet activation with microvascular function and related myonecrosis. Methods and results Patients (n=66) undergoing elective percutaneous coronary intervention (PCI) in long lesions were randomised 1:1 to either BVS or EES. The primary endpoint was the difference between groups in changes of pressure-derived corrected index of microvascular resistance (cIMR) after PCI. Periprocedural myonecrosis was assessed by high-sensitivity cardiac troponin T (hs-cTnT), platelet reactivity by high-sensitivity adenosine diphosphate (hs-ADP)-induced platelet reactivity with the Multiplate Analyzer. Post-dilatation was more frequent in the BVS group, with consequent longer procedure time. A significant difference was observed between the two groups in the primary endpoint of ΔcIMR (p=0.04). hs-ADP was not different between the groups at different time points. hs-cTnT significantly increased after PCI, without difference between the groups. Conclusions In long lesions, BVS implantation is associated with significant acute reduction in IMR as compared with EES, with no significant interaction with platelet reactivity or periprocedural myonecrosis.

BACKGROUND: Coronary microvascular dysfunction before percutaneous coronary intervention (PCI) predicts PCI-related myocardial injury in patients with stable coronary artery disease (CAD). Whether the dynamic changes of the microcirculation during PCI might be associated with the occurrence of procedure-related myocardial injury and infarction is still unclear. We aimed to investigate the impact of pre- and post-PCI microvascular function, evaluated with the index of microvascular resistance (IMR) on the occurrence of PCI-related myocardial injury and infarction. METHODS: In consecutive patients with stable CAD referred for elective PCI, coronary physiological indexes, including IMR, were measured before and after revascularization. High sensitivity Troponin T (hs-TnT) was assessed up to 24 h after PCI, and PCI-related myocardial injury and type 4a myocardial infarction (MI) were defined according to the fourth universal definition of myocardial infarction. RESULTS: In the 50 patients enrolled, a significant correlation was found between maximum post-PCI hs-Tn and IMR, both at baseline (rho = 0.309, p=0.029) and post-PCI (rho = 0.378, p=0.007). Patients who developed type 4a MI, compared with patients who did not, presented significantly higher IMR levels, both at baseline (28.3 ± 12.2 vs. 19.6 ± 8.8, p=0.020) and post-PCI (45.4 ± 21.3 vs. 21.6 ± 11.2, p 38 showed significantly higher maximum post-PCI hs-Tn levels (105.4 [49.4-126.9] vs. 22.4 [11.7-38.6] ng/ml, p

Saphenous vein grafts (SVGs) are still commonly used for surgical revascularization of coronary arteries although are related to poor long-term patency rates (1-4). “Full arterial” revascularization in coronary artery bypass graft (CABG) procedures, despite related to an improved clinical outcome, is still seldom achieved (5-7).

Management can be considered the science of decisions. Different researchers and practitioners have analysed the contents and boundaries of this vibrant domain, proposing multiple contributions and several perspectives. After a short overview of the principles of scientific management and their contribution to the definition of the modern idea of business management, this chapter briefly introduces the topics of subjectivity, complexity and uncertainty as relevant challenges to face in decision-making processes. The aim is to identify the key dimensions of the decision-making process over time. Lastly, systems thinking, and specifically the Viable Systems Approach (vSa), is proposed as a relevant interpretative lens to overcome the limitations of a traditional reductionist view and better understand the challenges and dynamics of post-modern social and economic dynamics.

Background— Fractional flow reserve (FFR) measurement of intermediate coronary stenoses is recommended by guidelines when demonstration of ischemia by noninvasive testing is unavailable. The study aims to evaluate the penetration of this recommendation into current thinking about revascularization strategies for stable coronary artery disease. Methods and Results— International Survey on Interventional Strategy was conducted via a web-based platform. First, participants’ experiences in interventional cardiology were queried. Second, 5 complete angiograms were provided, presenting only focal intermediate stenoses. FFR and quantitative coronary angiography values were known; however, remained undisclosed. Determination of stenosis significance was asked for each lesion. In cases of uncertainty, the most appropriate adjunctive invasive diagnostic method among quantitative coronary angiography, intravascular ultrasound, optical coherence tomography, or FFR needed to be selected. International Survey on Interventional Strategy was taken by 495 participants who provided 4421 lesion evaluations. In 3158 (71%) decisions, participants relied solely on angiographic appearance that was discordant in 47% with the known FFR, using 0.80 as cutoff value. The use of FFR and imaging modalities was requested in 21% and 8%, respectively. Comparing 4 groups of participants according to the experience in FFR, angiogram-based decisions were less frequent with increasing experience (77% versus 72% versus 69% versus 67%, respectively; P P P Conclusions— The findings confirm that, even when all potential external constraints are virtually eliminated, visual estimation continues to dominate the treatment decisions for intermediate stenoses, indicative of a worrisome disconnect between recommendations and current practice.

The present chapter builds on performativity research and investigates the performative role of value propositions in shaping a service ecosystem. Performativity is used as a central concept in illustrating how actors influence reality through their representations and their practices. In the investigation, Benefit corporations (hereafter B-corporations) serve as the context for empirical research. The work shows how ideas—the pre-constitute aspects of the ecosystem, such as values, norms and meaning—participate in shaping reality (i.e. the ecosystem) through the translation of such ideas into practice. The performative role of value propositions emerges as a bridge between actors’ values, aims, and practices in shaping a service ecosystem as well as increasing ecosystem viability.