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La patologia infettiva del tratto vulvovaginale

Bacterial vaginosis (BV) is the most common cause of vaginal discomfort in women. It is characterised by abnormal vaginal microbiota with a depletion of lactobacilli and predominance of anaerobic microorganisms, mainly Gardnerella vaginalis and Atopobium vaginae. Although antibiotics represent an effective therapeutic option in the short-term, recurrent infections still remain a serious problem. Nowadays, evidence exists about the efficacy of probiotics for the management of BV. The aim of the current double blind, randomised clinical trial was to assess the efficacy of a probiotic mixture, including Lactobacillus acidophilus GLA-14 and Lactobacillus rhamnosus HN001, in combination with bovine lactoferrin, as adjuvant therapy to metronidazole in women with recurrent BV. In particular, normalisation of Nugent score, remission of symptoms and recurrences during a six-months follow-up were assessed. 48 adult women received metronidazole (500 mg twice daily) for 7 days and randomly assigned to take simultaneously either probiotics plus lactoferrin or placebo (2 capsules/day for 5 days followed by 1 capsule/day for 10 consecutive days; induction phase). The verum or placebo administration (1 capsule/day for 10 consecutive days) was repeated each month (maintenance phase) during the six months of follow-up starting the first day of menstrual cycle since the menstrual blood increases the vaginal pH and contributes to increase the risk of recurrences. The results showed that symptoms (vaginal discharge and itching), Nugent score and recurrence rate were significantly improved by probiotics mixture in association with lactoferrin. This alternative approach may represent a safe and effective remedy for the restoration of healthy vaginal microbiota in preventing recurrent BV.

Mannose-binding lectin (MBL) is a recognition molecule of the complement (C) system and binds to carbohydrate ligands present on a wide range of pathogenic bacteria, viruses, fungi, and parasites. MBL has been detected in the cervico-vaginal cavity where it can provide a first-line defence against infectious agents colonizing the lower tract of the reproductive system. Analysis of the cervico-vaginal lavage (CVL) obtained from 11 normal cycling women at different phases of the menstrual cycle revealed increased levels of MBL in the secretive phase. Part of this MBL derives from the circulation as indicated by the presence of transferrin in CVL tested as a marker of vascular and tissue permeability. The local synthesis of MBL is suggested by the finding that its level is substantially higher than that of transferrin in the secretive phase. The contribution of endometrium is negligible since the MBL level did not change before and after hysterectomy. RT-PCR and in situ RT-PCR analysis showed that the vaginal tissue, and in particular the basal layer of the epithelium, is a source of MBL which binds to the basal membrane and to cells of the outer layers of the epithelium. In conclusion, we have shown that MBL detected in CVL derives both from plasma as result of transudation and from local synthesis and its level is progesterone dependent increasing in the secretive phase of the menstrual cycle.

Chlamydia trachomatis is one the most important sexually transmitted diseases; it can cause serious sequelae despite the absence of symptoms in some people. It's estimated that about 25% of women who have acute salpingitis become infertile, and chlamydial infection is the commonest cause. The introduction of screening programs for its detection are still a topic of discussion. The literature shows that the total cost of examination and treatment of complications known to be associated with genital chlamydial infection (PID, chronic pelvic pain, tubal factor infertility) is generally higher than the total cost of a large-scale Chlamydia screening program. The selection of a diagnostic test for detection of chlamydial genital infection depends on availability, local expertise, and prevalence of Chlamydia trachomatis in the test population. Cell culture is too expensive in nonendemic regions, so the use of non-culture techniques is very attractive. PCR (polymerase chain reaction) and LCR (ligase chain reaction) are actually the two most commonly used alternatives to conventional methods for detecting STD agents. In fact, PCR and LCR have proved useful for detection of Chlamydia trachomatis in cervical and urethral samples both in symptomatic and asymptomatic women. Recently, testing of first-void urine (FVU) specimens with these techniques has shown that the amplification tests are as sensitive as tests with endocervical swab cultures.

In this study we developed an in situ protocol for quantitative detection of high-risk human papillomavirus (HPV), based on direct in situ polymerase chain reaction (PCR) with SYBR Green I labeling and GeneAmp 5700 Sequence Detection System technology. This protocol was applied on cytological specimens of patients with cervical intraepithelial neoplasia (CIN) and squamous cell carcinoma (SCC). We performed direct in situ quantitative PCR on cell smears, uninfected human skin fibroblasts, Hela and Caski cells. After in situ amplification, slides were counterstained with propidium iodide and analyzed under a fluorescent microscope in order to localize high-risk HPV and verify preservation of morphology. After PCR optimization, we obtained the following results. The Hela cells showed values ranging from 15 to 33 copies of high-risk HPV per cell, the Caski cell line from 220 to 300 high-risk HPV copies per cell and the cell smear (both CIN and SCC) around 20-35 copies of high-risk HPV per cell. No high-risk HPV amplification was detected in uninfected human fibroblasts, healthy controls, non-amplification control, and non-specific primer control. A positive intranuclear high-risk HPV amplification was detected in cell smears from 20 patients with CIN and 10 with SCC. In conclusion, our in situ quantitative protocol for high-risk HPV detection on cell smears combines both quantitative data and in situ localization of the target, with preservation of morphology. For this reason it could be used as a rapid screening tool when both morphological and quantitative results are requested on the same slide.

Summary The goals of antibacterial prophylaxis during obstetric/gynaecological surgery are similar to those of prophylaxis during intra-abdominal surgery. The vaginal flora consists of many aerobic and anaerobic organisms, is dominated by peroxide-producing lactobacilli, and is non-pathogenic under normal conditions. Destabilization of the vaginal ecosystem, as in bacterial vaginosis (BV), causes a massive increase in the ratio of anaerobes to aerobes and is associated with a large increase in the risk of infection. The surgical procedures at most risk of postoperative infection are vaginal, abdominal and radical hysterectomy and caesarean section. Both the American College of Obstetricians and Gynecologists and the American Society of Health-System Pharmacists have recommended single-dose prophylactic protocols using a variety of agents (penicillins, cephalosporins and clindamycin). However, it remains doubtful whether prophylaxis is used widely. In Italy, such prophylaxis has proved less effective in women with BV. Accordingly, patients with confirmed BV are given topical clindamycin for 7 days leading up to surgery, in addition to the usual prophylactic regimen. Caesarean delivery carries a 5- to 20-fold greater risk of infection that normal vaginal delivery. A meta-analysis of 66 clinical studies has shown that any prophylactic regimen is effective in reducing postoperative complications. The use of prophylaxis in patients undergoing a low-risk caesarean section remain controversial.

BACKGROUND: Recurrence is a frequent complaint of patients with vulvovaginal candidiasis (VVC). Although the pathogenesis of VVC remains a controversial issue, disruption of the balance between the vaginal microbiota may facilitate overgrowth by Candida. Some probiotic bacterial strains can suppress Candida albicans; Lactobacillus plantarum P17630 is able to attach to vaginal epithelial cells and significantly reduce the adhesion of C. albicans. OBJECTIVE: To evaluate the effect of the application of Lactobacillus plantarum P17630 in restoring the vaginal microbiota and prevention of relapses among women with acute VVC undergoing conventional (azole) local and main therapy. METHODS: Retrospective comparative study. We recruited 89 women with a diagnosis of VVC, who were placed into two groups on the basis of reported treatment. The control group was treated with a daily dose of 2% clotrimazole vaginal cream at bedtime for 3 days, followed by vaginal application of a capsule containing lubricant once a day for 6 days and then once a week for another 4 weeks. The probiotic group was treated with the same azole-based protocol but followed by vaginal application of a capsule containing Lactobacillus plantarum P17630 (>10₈ CFU) once a day for 6 days and then once a week for another 4 weeks beginning the day following clotrimazole discontinuation. Clinical and diagnostic patterns were monitored for three months of follow-up. RESULTS: At the end of study the probiotic-treated women showed a statistically significant increase in Lactobacillus values "+++" (80% versus 40%, p5. CONCLUSION: Although the results of different studies are controversial, most have suggested use of probiotics in the prevention or treatment of VVC, and no adverse effects have been reported. Our data with L. plantarum P17630 (Gyno-Canesflor - Bayer) confirm the role of this specific strain as a potential empirical preventive agent for reducing vaginal discomfort after conventional treatment of acute VVC and shifting the vaginal milieu toward a predominance of lactobacilli with an improvement of the vaginal pH value.

PURPOSE: Sacral nerve modulation appears to offer a valid treatment option for some patients with fecal incontinence and functional defects of the internal anal sphincter or of the striated muscle. METHODS: Sixteen patients with fecal incontinence (4 males; mean age, 51.4 (range, 27–79) years) with intact or surgically repaired (n=1) anal sphincter underwent permanent sacral nerve stimulation implant. Cause was traumatic in two patients, and associated disorders included scleroderma (2 patients) and spastic paraparesis (1 patient); eight (50 percent) of the patients also had urinary incontinence, and two (12.5 percent) had nonobstructive urinary retention. All patients were selected on the basis of positive findings from at least one peripheral nerve evaluation. The stimulating electrode was positioned in the S2 (1 patient), S3 (14 patients), or S4 (1 patient) sacral foramen. RESULTS: Mean follow-up was 15.5 (range, 3–45) months. Mean preimplant Williams score decreased from 4.1±0.9 (range, 2–5) to 1.25±0.5 (range, 1–2) (P=0.01, Wilcoxon test), and the number of incontinence accidents for liquid or solid stool in 14 days decreased from 11.5±4.8 (range, 2–20) before implant to 0.6±0.9 (range, 0–2) at the last follow-up. Important manometric data were an increase in mean maximal pressure at rest of 37.7±14.9 mmHg (implantable pulse generator 49.1±18.7,P=0.04) and in mean maximal pressure during squeeze (prestimulation 67.3±21.1 mmHg, implantable pulse generator 82.6±21.0,P=0.09). CONCLUSIONS: Neuromodulation can be considered an option for fecal incontinence. However, an accurate clinical and instrumental evaluation and careful patient selection are required to optimize outcome.

One hundred and seventy-three patients, mean age 74 years permanently paced with 123 atrial (53 unipolar, 70 bipolar) and 143 ventricular (73 unipolar, 70 bipolar) pacing leads were included in this study. The pacing leads were recent generation low surface area steroid eluting leads from one manufacturer: leads with silicone and polyurethane insulation were studied, and they were combined with generations of one pacemaker family from the same manufacturer permitting identical measurements to be made over a follow-up of 2 years. Pacing threshold was measured using pulse duration at a fixed voltage of 1.5 V: peak to peak P and R wave amplitude and pacing impedance at 2.5 V and 0.5 ms were all measured using the manufacturer's standard programmer. Although many significant differences, in the parameters measures, existed between atrium and ventricle and unipolar and bipolar configurations, none was felt to be of clinical significance. These data permit the physician to choose the lead type with regard to sensing performance and long-term lead integrity.

PROBLEM: Endothelial cells (ECs), although similar in function and morphology, represent an heterogeneous population of cells in terms of secretion of inflammatory mediators, modulation of adhesion molecules, leakiness and pro-coagulant activity and play a fundamental role in the control of the inflammatory response. Excessive inflammation at foetal-maternal interface is thought to be a key contributor in a compromised pregnancy. Intrauterine infections have been associated with pregnancy complications such as preterm labor, intrauterine growth restriction and preeclampsia. We demonstrated that decidual endothelial cells (DECs) compared to ECs isolated from adult skin (ADMECs) are ipo-responsive to the pro-inflammatory stimulus LPS for the expression of adhesion molecules and cytokines secretion. We showed also that DECs express lower level of TLR4, MD2 and MyD88 compared to ADMECs and this may be important for the control of the inflammatory response at foeto-maternal interface. We have previously shown that DECs acquired the ability to synthesize C1q during pregnancy which is to a large extent localized on the cell surface. Since it has been demonstrated that C1q suppressed LPS-induced IL-12p40 production in bone marrow-derived DC (BMDC) we hypothesised that C1q can play a role in the control of DECs response to LPS. METHODS: We investigated the expression of TLR4, MD-2, and MyD88 in ADMECs previously incubated for two hours with C1q in cells stimulated or not with LPS by Real Time PCR, Western blotting and cytofluorimetric analysis. RESULTS: Our results showed that C1q affects mRNA expression of TLR4, MD-2, and MyD88 both in resting and in stimulated cells, CONCLUSION: The presence of C1q at foeto maternal interface may be responsible of the control of inflammation during pregnancy.

Objective To evaluate the prevalence of asymptomatic Chlamydia trachomatis genitourinary infection in women with human immunodeficiency virus (HIV) infection. Methods The prevalence of asymptomatic chlamydial genitourinary infection in HIV-seropositive women was compared with both HIV-seronegative controls and women with unknown HIV status. Chlamydia trachomatis was isolated in cell culture from endocervical and urethral specimens. Results The prevalence of genitourinary C trachomatis infection among HIV-seropositive women was 18.3% (21 of 115), a rate significantly higher than in both HIV-negative women (11 of 136; P = .016) and controls with unknown HIV status (18 of 326; P = .0001). Crude odds ratios for endocervical and urethral chlamydial infection in HIV-seropositive women compared to HIV-seronegative controls were 2.6 (95% confidence interval [CI] 1.13-6.08) and 3.3 (95% CI 1.15-9.67), respectively. After adjustment for variables related to sexual habits, there was no difference in the risk of cervical C trachomatis infection between HIV-seropositive cases and HIV-seronegative controls (Mantel-Haenszel odds ratio 1.04, 95% CI 0.93-1.14; P = .41). Finally, in HIV-seropositive patients, both the severity of immunosuppression evaluated by CD4+, CD8+, and total lymphocyte counts and the detection of p24 HIV-related antigen did not correlate with the presence of chlamydial infection. Conclusions Women infected with HIV are at high risk for asymptomatic genitourinary chlamydial colonization. To prevent a possible "epidemic" of pelvic inflammatory disease, appropriate screening programs and therapeutic strategies should be planned.

The complement system is one of the major components of humoral innate immunity, acting as one of the first lines of defence against microbes, but new roles in inflammatory and immunological processes are emerging. The placenta undergoes an intense process of tissue remodelling which leads to the activation of the complement (C) system resulting in the release of potentially destructive activation products that need to be neutralized. The protection of the foetus against maternal C activation products is achieved by the surface expression of regulators. The liver is the main source of the plasma C components although extra-hepatic synthesis in several tissues and organs has been documented. The data collected recently indicate that trophoblast cells are able to secrete C3 and C4 and the recognition molecule C1q, contributing to the local synthesis at the placental level. Besides trophoblast cells, decidual endothelial cells acquire the ability to synthesize and express C1q on the cell surface. All these observations support the role of C1q in the placental development and its importance in trophoblast endovascular and interstitial invasion. In conclusion it is increasingly evident that a new role of complement and in particular C1q in the processes of tissue homeostasis as well as is in inflammation and infection is now emerging.

The mean counts of Langerhans' cells were evaluated in cervical biopsies obtained from 30 patients with human immunodeficiency virus (HIV) infection and cervical intraepithelial neoplasia (CIN) and from 30 HIV-seronegative control patients. Each HIV-seronegative control was matched to a seropositive case with respect to grade of CIN, age, and smoking habits. Langerhans' cells were identified by immunohistochemical staining for S-100 protein. In situ hybridization with biotinylated probes was performed to detect human papillomavirus (HPV) DNA 6/11, 16/18, and 31/35/51. The mean counts of S-100 positive cells per 100 basal cells were lower in HIV-seropositive patients than in controls (0.99 +/- 0.08 vs 1.9 +/- 0.2 P = 0.024). These differences occurred independent of any coexisting HPV infection. Positive correlations between S-100 positive cell counts and CD4+ and CD8+ cell counts were found in HIV-infected women. AIDS patients had lower Langerhans' cell counts compared both to patients with AIDS-related complex or asymptomatic HIV infection. Our results suggest that local cervical immunity, as evaluated by Langerhans' cell counts, is impaired in HIV-seropositive women. The severity of impairment seems to correlate with the stage of the HIV disease.

Bacterial vaginosis (BV) is a common condition characterised by a polymicrobial disorder, with an overgrowth of several anaerobic or facultative bacteria and with a reduction or absence of lactobacillus colonisation. The prevalence of BV ranges from 4 to 64%, depending on the racial, geographic and clinical characteristics of the study population. In asymptomatic women, the prevalence varies from 12 to 25%, and similar percentages are observed in pregnant women. Although BV is associated with several adverse outcomes, such as upper genital tract infections, pelvic inflammatory disease, endometritis, preterm birth and low birthweight, many basic questions regarding the pathogenesis of BV remain unanswered. Mucosal immune system activation may represent a critical determinant of adverse consequences associated with BV. An unequal risk for BV acquisition and\or recurrence could derive from different mucosal immune host abilities and\or capability of invading microbes to produce factors that inactivate the local immune response. BV is associated with a two-fold increased risk of preterm birth, with the greatest risk when BV is present before 16 weeks of gestation (odds ratio = 7.55). This may indicate a critical period during early gestation when BV-related organisms can gain access to the upper genital tract and set the stage for spontaneous preterm labour later in gestation. The results of treatment trials for pregnant women with BV have been heterogeneous, with anywhere from an 80% reduction to a two-fold increase in preterm birth among women who received treatment. For this reason, in current clinical practice significant controversy surrounds determining not only who and when to screen but also who and how to treat. Recent evidence shows that individual genetic backgrounds can affect chemokine production. This is an interesting area for future research and could lead to trials of treatment only for women genetically predisposed to preterm birth. Keywords Antibiotics, bacterial vaginosis, immune response, preterm birth, vaginal pH.

During the development of human placenta, extravillous trophoblast (EVT) departs from anchoring chorionic villi and invades the maternal decidua. Immunohistochemical analysis of decidua obtained from voluntary abortions showed that C1q was widely distributed in the decidual stroma with intense staining around invading trophoblast, while undetectable in non pregnant uterus. Based on these findings, we hypothesized that C1q may be involved in the migration of EVT. To this end, we investigated the ability of EVT to adhere to solid-phase bound C1q and to migrate using a transwell model system with inserts coated with C1q. Our results showed that EVT strongly adhered to C1q to an extent similar to that observed for cell adhesion to fibronectin, a component of the extracellular matrix of decidua. Adhesion of EVT to C1q was inhibited by antibodies to gC1qR, which was detected on these cells by FACS analysis. Cells bound to C1q and to FN exhibited a markedly different morphological appearance. The cells attached to FN were spread out whereas those bound to C1q were much smaller with wide ruffles extending in multiple direction. EVT spread on FN contained a high number of actin-containing stress fibers as revealed by phalloidin staining as opposed to the peripheral distribution of actin in cells bound to C1q. C1q was also found to promote the migration of EVT, though to a lesser extent than FN. Interestingly, RT-PCR analysis showed that EVT expressed mRNA for the three chains of C1q. In conclusion, our results suggest that C1q is produced by EVT of maternal decidua and play a role in the migration and adhesion of these cells to the extracellular matrix of the decidua.

SummaryIn our study we examined the early complement components in patients with bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and in healthy controls. The levels of C1q, mannose-binding lectin (MBL) and C3 were measured by ELISA in the cervicovaginal lavage (CVL) from gynaecological patients and controls. No significant differences were observed in the levels of these proteins in the three study groups. Immunofluorescence analysis of the clue cells and Candida hyphae from BV and VVC patients for surface-bound complement components showed the presence of C3, while C1q was undetectable. MBL was revealed on clue cells but not on Candida. Binding of MBL to Candida, grown or cytocentrifuged from the CVL of VVC patients, was found to be pH dependent and occurred between pH 4·5 and pH 5·5. In conclusion, we demonstrated that MBL and C3 present in the vaginal cavity act as recognition molecules for infectious agents that colonize the cervicovaginal mucosa. Our finding that MBL, but not C1q, binds to bacteria and fungi in vagina suggests that the lectin and classical pathways of complement activation may play a different role in immune defence in the female genital tract.

In order to assess the usefulness of amniotic fluid α-fetoprotein (AFP) levels at the time of midtrimester genetic amniocentesis, 4,430 cases were retrospectively studied to compare the high, normal or low AFP values with the karyotype characteristics and fetal anatomy using ultrasound (US) scanning and confirmed by postnatal evaluation or necroscopy in the case of termination of pregnancy. All the cases presenting malformations were correctly diagnosed by US examinations. AFP levels over the 2nd standard deviation (SD) were found in 112 cases (2.52%) and below the 2nd SD in 11 cases (0.24%). The characteristics of these cases are presented and discussed. According to our results, it is concluded that routine assessment of AFP at the time of midtrimester genetic amniocentesis, if coupled with optimal US scanning, is no longer justified.

Sexually transmitted diseases (STD) have their most incidence in adolescence. We conducted an observational study on the symptomatic patients of our STD's office to evaluate epidemiological distribution, behavioral patterns and diffusion of genital infections in teen-agers in respect of the adult population.From april 1996 to april 1999 we studied two groups of patients: 54 teen-agers (13-19 years) and 917 women in fertile age (20-40 years). All the patients underwent to a clinical and microbiological examination of vaginal secretions (Gram slide, wet mount, cultures for bacteria, yeasts, eventually Chlamydia trachomatis, Mycoplasma spp, Neisseria gonorrhoeae, Herpes simplex virus--HSV--) and to an anamnestic and socio-epidemiological questionnaire.The more frequent genital infections among adolescents was vulvovaginal candidiasis (35% vs. 23.9% of adult people). HSV was found in 1.8% of teen-agers (vs. 0.6%) and when requested, Chlamydia trachomatis and mycoplasmas was found respectively in 16.6% (vs. 1.1%) and 50% (vs. 28%) in adolescents. We observed a high percentage of pregnancy (22.2%) of voluntary pregnancy interruption (41.6%) and a specific sexual behavior among teenagers.Our data show a particular behavioral risk pattern in the adolescence population and indicate the necessity of a serious program of prevention and sexual education that allow young people to live with more consciousness and safety their sexuality.

This prospective, randomized, controlled study compared the effects of recombinant human FSH (r-hFSH) and highly purified urinary FSH (u-hFSH HP) on lipoprotein(a) [Lp(a)] concentrations in women undergoing ovarian stimulation. Fifty infertile women were randomly allocated into two equally sized treatment groups (n = 25 per group). Thirty normal ovulation women were recruited as controls. The infertile women received u-hFSH or r-hFSH 150 IU/day starting on cycle day 2. From cycle day 6 the dose was adjusted according to ovarian response. Human chorionic gonadotrophin 10,000 IU was administered once there was at least one follicleor =18 mm in diameter. The luteal phase was supported with progesterone 50 mg/day for at least 15 days. Repeated measurements of Lp(a) concentrations were performed during both stimulated and natural cycles. A significant increase in luteal phase Lp(a) concentrations was detected in the stimulated cycles, whereas no significant changes in serum Lp(a) concentrations were observed during natural cycles. There were no significant differences between the urinary and recombinant FSH effects on serum Lp(a). The luteal Lp(a) increase was transitory because after 1 month Lp(a) concentrations returned to baseline values if pregnancy failed to occur; in pregnant women persistent increased Lp(a) concentrations were found at the 8th week. The percentage changes in serum Lp(a) were positively correlated with the luteal progesterone increase (r = 0.40, P0.05), but not with follicular or luteal oestradiol increase. The women with low baseline Lp(a) (or =5 mg/dl) had a greater increase of the Lp(a) concentrations at midluteal phase than women with baseline Lp(a)5 mg/dl. In conclusion, the recombinant or urinary hFSH administration does not directly influence Lp(a) concentrations. The luteal Lp(a) increase in stimulated cycles is not related to gonadotrophin treatment per se, but appears to be related to the high luteal progesterone concentrations, physiologically or pharmacologically determined. Our results also suggest that the sensitivity to the progesterone changes could be related to apolipoprotein(a) phenotype.

Aim A prospective randomized trial was set up to evaluate contractile parameters and quality of life in patients with congestive heart failure. Methods and Results We describe the results from 38 patients in sinus rhythm and with chronic heart failure due to congestive cardiomyopathy, prospectively randomized to optimal medical therapy (Group 1, 19 patients) or optimal medical therapy plus dual chamber pacemaker programmed to optimal AV delay (Group 2, 19 patients). At a 6 month follow-up, 7/19 patients in Group 1 had died compared with 5/19 patients in Group 2. During follow-up, there were few significant changes in evaluated parameters except for mitral regurgitation time, which was prolonged in Group 1 and shortened in Group 2. The systolic left ventricular diameter shortened significantly only in Group 2. An energy and activity questionnaire showed that the eVect of DDD pacing in the latter patient population was beneficial. Conclusions From these results we may conclude that at the 6 month follow-up DDD pacing with echo-optimized AV interval programming can improve quality of life without affecting survival.

Adolescence in the age bracket with the highest incidence of sexually transmitted diseases (STDs). An observational study was performed in symptomatic patients attending our Outpatient Clinic for STDs in order to evaluate the diffusion of genital infections in the adolescent population and the different epidemiological distribution compared to adults.The incidence of these infections was compared in two groups of patients attending the clinic between April 1995 and April 1999. The first consisted of 54 teenagers (13-19 years-old) and the second, used as a control, consisted of 917 women of child-bearing age (20-40 years). All patients underwent clinical examinations and microbiological tests of vaginal secretions (bacterioscopic test on coloured plates using the Gram method, cold tests, cultural assay of bacteria and fungi, assay for (Chlamydia trachomatis, Mycoplasma spp., Neisseria gonorrhoeae, Herpes simplex virus).The most common genital infection in teenagers was candidosis (35% vs 23.9%), followed by bacterial vaginosis (31.9% vs 25.8%) and mixed flora vaginitis (25.9% vs 22.6%). HSV was found in 1.8% of adolescents (vs 0.6%), in selected cases, Chlamydia and Mycoplasma were present in 16.6% (vs 1.1%) and 50% (vs 28%) of teenagers respectively.All genital infections were more frequent in the study population of adolescents compared to the control group. The adolescent population should be the target of a serious and systematic programme of prevention in order to ward off the sequelae of early and often irresponsible sexual activity.

Adolescence represents the period with the highest frequency of negative consequences associated with sexual activities (sexually transmitted diseases and unwanted pregnancies). An epidemiological study was carried out in symptomatic patients attending our Outpatient Clinic for Sexually Transmitted Diseases between April 1995 and April 1999 in order to evaluate the behaviour pattern of the adolescent population and identify the differences compared to the adult population.A questionnaire was used to assess the characteristics of two groups of patients: the first consisted of 54 teenagers (13-19 years-old) and the second, the control group, consisted of 917 women aged between 20 and 40 years old.A high percentage of pregnancies (22.2%) and voluntary abortions (41.6%) was observed in teenagers, associated with different sexual behaviours. The age of sexual intercourse was below 15 in 44.4% of adolescents (vs 7.7% of controls), whereas 61.1% had more than one sexual partner and 20.4% had changed partners in the last 6 months (vs 7.4%). 50% of teenagers did not use any method of contraception (vs 44.2%) and barrier methods were only used by 20.4% (vs 18.4%).Our study confirms the existence of a high-risk behavioural pattern in the adolescent population and draws attention yet again to the need for a serious programme of prevention and sexual education which will allow adolescents to experience the discovery of their own sexuality with greater awareness and safety.

Background and method Recently, various dedicated atrial pacing algorithms have b een proposed to prevent atrial fibrillation (AF). Consistent atrial pacing (CAP; an algorithm for automatic atrial overdrive) and atrial rate stabilization (ARS; an algorithm for preventing the 'short-long' sequences) were tested in 16 patients with brady-tachy syndrome and recurrent paroxysmal AF (‡3 episodes per month). Results In the population as a whole, pacing with CAP was associated with a significant reduction in AF burden in comparison with DDDR pacing. With regard to the effects on AF burden, 11 patients (69%) were found to benefit significantly from CAP or ARS pacing algorithms (reduction >50% in AF burden). In detail, seven patients were responders to both algorithms, two to CAP only and two to ARS only. Two patients exhibited a significant increase in AF burden with the ARS algorithm. With regard to the effects on number of mode switches per day, seven patients (44%) were found to benefit significantly from CAP or ARS pacing algorithms (reduction in mode switches per day >50%). In detail, five patients were responders to both algorithms and two to ARS only. Two patients had a significant increase in the number of mode switches per day with both CAP and ARS algorithms. Conclusion The response to ARS and CAP algorithms is heterogeneous. In 31‐69% of patients with brady-tachy syndrome a significant reduction in AF burden and/or mode switch episodes can be obtained with ARS and/or CAP algorithms; however, in a few patients an increase in AF episodes and/or AF burden may occur (Eur Heart J Supplements 2001; 3 (Suppl P): P7‐P15)

According to some authors, vaginal delivery always causes denervation of perineum and the greater the damage the longer the second labour phase (the so-called "delivering phase"). Therefore, it is necessary to reduce the number of too prolonged labours, but it is equally important to avoid an uncontrolled increase of cesarean sections. In order to achieve this objective, it is important to carry out a careful selection among laboring women and choose those most at risk for whom cesarean section is strongly recommended. On the basis of the data collected by the medical literature and in consideration of the pathogenetic role of the outlet dystocia, we have tried to identify a simple and effective prognostic index resulting from the different pelvimetric and ultrasonographic parameters.In 72 full-term pregnant women, we have taken into account the ultrasonographic parameters expressing the fetal dimension (cephalic diameters, cephalic and abdominal circumferences, estimated fetal weight according to Haddlok), the outlet pelvic diameters (trans-ischial and coccygeal-pubic) and a fetal-pelvic index derived from these parameters.If taken individually, these parameters do not seem to have any direct connection with the length of the delivering phase, but the combination of the cephalic and external pelvimetric diameters has produced a significative statistical coefficient.On the basis of the data collected, it is suggested that a careful evaluation of external pelvimetric and cephalic parameters would be useful from the clinical point of view.

Given that an increased peripheral insensitivity to insulin represents the primum movens of gestational diabetes, it is reasonable to suppose that the determination and evaluation of the insulinemic response to an oral glucose loading test may represent a simple, effective and low cost screenign test. A method was devised which consisted in performing two assays of insulin and glycemia in venous blood; the first while fasting, the second one hour after the ingestion per os of 50 g glucose.A group of 79 pregnant women, aged between 20 and 41 years old (mean age 30.5), was tested in around the 23rd week of gestation. All women were attending the Obstetric and Gynecological Clinic at Trieste University.Based on the results obtained, insulinemic parameters appear to be significantly correlated with data for the short glycemic curve according to O'Sullivan-Mahan.This study appears to confirm the need to include insulinemic tests as part of the new and more efficacious glucose tolerance tests and to perform prospective studies in order to identify the most reliable screening method in terms of sensitivity and specificity, also in relation to the cost-benefit ratio.

The aim of this Italian multicentre study was to evaluate the haemodynamic and antiarrhythmic effects of DDIR versus DDI pacing mode in sick sinus syndrome with chronotropic incompetence.Seventy-nine patients were implanted with a dual chamber rate-responsive pacemaker (Medtronic 7075) and centrally randomised to DDI or DDIR pacing mode. After six months, the pacing modality was crossed over. Follow-up included clinical data, rest ECG, echocardiography, Holter monitoring and exercise testing in DDIR.a) Haemodynamic effects. Comparing postimplant exercise testing in DDIR mode with preimplant tests, peak heart rate increased from 96 +/- 17 to 115 +/- 17 bpm (+20%, p0.0001), total work capacity from 7.0 +/- 3.5 to 8.8 +/- 4.3 minutes (+26%, p0.0001), peak oxygen uptake from 1238 +/- 406 to 1453 +/- 423 ml/min (+17%, p0.001) and oxygen uptake at anaerobic threshold from 977 +/- 343 to 1222 +/- 415 ml/min (+25%, p0.001). These benefits persisted unchanged during one-year follow-up. b) Antiarrhythmic effects. After six months, paroxysmal atrial fibrillation recurrence significantly decreased in the whole population: group I (DDI) 20.7 vs 48.3%, p0.02; group II (DDIR) 21.2 vs 36.4%, p0.05; group I + II (DDI + DDIR) 21.0 vs 41.9%, p0.001. After one year no significant differences were found between DDI and DDIR. Group I: DDI 23.8 vs DDIR 28.6%, ns; group II: DDI 22.7 vs DDIR 18.2%, ns.DDIR vs DDI significantly improves short- and long-term haemodynamic performance. Dual chamber pacing shows a significant reduction of paroxysmal atrial fibrillation recurrence, regardless of rate responsiveness.

Particular conditions exist at the end of some pregnancies which cause an increase in maternal and fetal risk. A valid alternative for these pregnancies is represented by the administration of prostaglandins, in order to obtain labor induction. The goal of our study was to define the eligibility criteria and the epidemiological characteristics that correlate most with a favorable obstetrical outcome. The study was conducted on 133 informed, consenting patients subjected to labor-induced delivery with prostaglandins E2. The mode of delivery in relationship to parity demonstrated that the pluriparous patients had fewer difficulties in labor and in its induction: of the 43 pluriparous cases, none had a cesarean section for failed induction and 95.3% delivered vaginally. One hundred percent of the patients with a Bishop score of more than 4 went into labor, as opposed to 81% of the patients with a score of less than 4. Therefore, taking into consideration the cost of the method, we retain that choosing an active position is valid, respecting the eligibility criteria for the induction of labor described above.

To evaluate the safety and efficacy of a new algorithm for automatic mode switching (AMS) from DDD-DDDR to DDIR, 26 patients, 16 females and 10 males, mean age 73 +/- 6 years of age, affected by sinus node disease, chronotropic incompetence, and recurrent paroxysmal atrial fibrillation (PAF) received the Medtronic Thera DR pacemaker. The device continuously calculates, in ms, the running average of the intrinsic atrial rate (MAR) and compares the current atrial interval (CAI) with the stored MAR. When the CAI is greater than the MAR it increases by 8 ms, and when the CAI is less than the MAR, it decreases by 23 ms. When MAR < or = 330 ms (182 beats/min), tachycardia is detected and AMS is activated. All patients had clinical evaluation, 12-lead ECG, Holter monitoring, and exercise testing after implantation and every 3 months for 1 year. The results were compared with the data stored in the pacemaker memory: AMS episodes number; the histogram of the last 14 episodes; and atrial electrogram recording. Twenty-two Holter recordings in 13 patients showed PAF and in all of them AMS occurred simultaneously. AMS lasted between 10 seconds and 20 hours, and MAR ranged from 195-400 beats/min. No episode of PAF and no AMS were recorded in 39 Holter recordings in 22 patients. Appropriate AMS was confirmed in five patients by stored atrial electrogram and in nine by 12-lead ECG and pacemaker event markers. Mean atrial sensing was 2.13 +/- 1.04 mV during PAF and 3.18 +/- 1.46 mV during sinus rhythm. No PAF episode and no AMS were recorded during exercise testing. In conclusion, this new algorithm was very reliable, sensitive, and specific.

A multicenter study evaluated the performance of atrial and ventricular unipolar leads with porous steroid-eluting and platinized grooved electrodes. A total of 563 leads were implanted in 451 patients. These included 311 ventricular and 97 atrial steroid-eluting electrodes; and 112 ventricular and 43 atrial leads with platinized electrodes. Mean follow-up wasor = 1 year. At implant there were no significant differences in threshold parameters in either chamber. Chronically, however, the steroid-eluting lead consistently had significantly lower pacing thresholds in both chambers. For example, after 360 days implant, steroid-eluting electrodes had 0.23 +/- 0.10 msec ventricular thresholds at 0.8 V compared to 0.45 +/- 0.3 msec in the platinized group (P0.0001). In the atrium, the steroid-eluting lead's 6-month thresholds at 0.8 V were 0.15 +/- 0.06 msec compared to 0.9 +/- 0.8 msec for the platinized electrode (P0.01). The chronic ventricular QRS amplitudes were significantly greater for the steroid-eluting electrode (P0.0005). There were no significant differences in atrial sensing and no incidence of atrial undersensing in the study. The low and consistent thresholds of the steroid-eluting electrodes would have permitted pacing in the ventricle ator = 2.5 V without compromising safety factor in 99.4% of the patients. The other 0.6% required 5 V temporarily. In the atrium, 100% of the patients could have been paced safely at reduced output. In spite of this, 63% of the implanters lacked the confidence to use reduced outputs.

Problem: During pregnancy, an adequate inflammatory control is essential for normal intrauterine foetus development. Vascular endothelium is known to play a critical role in regulation of inflammatory processes. We hypothesize a different ability of decidual endothelial cells (DEC) compared to endothelium from other districts to respond to inflammatory stimuli. Material and Methods: DEC were isolated and activated with inflammatory stimuli and their response in term of adhesion molecules expression, vascular leakage and cytokines production was evaluated. These data were compared to the data obtained with HUVEC and microvascular endothelial cells isolated from human skin (ADMEC) and from human endometrium (UtMEC). Results: Our observations indicate that DEC: 1. express low levels of adhesion molecules after inflammatory stimulation 2. are unable to respond to classic permeabilizing stimuli 3. present a different cytokine profile. Conclusions: Our results indicate that decidual endothelium has a different resting phenotype and shows an anti-inflammatory behavior compared to other microvascular endothelium.

The authors report a case of post-traumatic diaphragmatic hernia with non specific clinical findings. They consider the etiopathogenetic factors, clinical findings, therapy and underline the importance of well-performed remota anamnestic procedure to recognise the illness fastly.

OBJECTIVE To evaluate risk factors related to anamnestic variables, sexual behavior, feminine hygiene habits, and microbiologic findings in women with idiopathic recurrent vulvovaginal candidiasis. METHODS We conducted a multivariate observational study comparing sociodemographic, anamnestic, clinical, and microbiologic variables between 86 patients with recurrent vaginal candidiasis and 180 controls with nonrecurrent infection. RESULTS In logistic regression analysis, women with recurrent candidal vaginitis were more likely than controls to use contraceptive pills (adjusted odds ratio 2.0, 95% confidence interval [CI] 1.02-3.91; P = .04) and commercially available solutions for either vulvoperineal cleansing (adjusted odds ratio 2.2, 95% CI 1.25-3.88; P = .007) or vaginal douching (adjusted odds ratio 1.8, 95% CI 1.0-3.26; P = .05). The rate of isolation of non-albicans candida species was significantly higher among cases than controls (adjusted odds ratio 3.0, 95% CI 1.50-6.04; P = .005). Finally, increasing frequency of monthly sexual intercourse was significantly correlated (chi 2 for trend = 4.87; P = .027) with recurrent infection. CONCLUSION Several behavioral factors seem to influence the occurrence of relapses in recurrent vulvovaginal candidiasis. Appropriate counseling about contraception, sexual activity, and personal hygiene habits could be an important preventive measure in these cases.