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Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of the motor neuron, which selectively affects it both at central (first motor-neuron) and peripheral level (second motor-neuron). The disease shows up at a mean age of 56 years and the most affected are males. Although ALS may start as a bulbar or spinal disease, with the progression of the disease typically both become evident. Pharmacological approved treatments for ALS are still limited and include riluzole and edaravone which improve survival over time. Despite this, ALS leads to progressive muscle involvement and requires a complex multidisciplinary approach to manage increasing disability which goes beyond motor neurons. Sialorrhea is, amongst others, one of the most disabling symptoms in ALS. The complexity in managing saliva is due to a muscular spasticity and to a scarce palatino-lingual muscles control, rather than to an overproduction of saliva. These features could increase the risk of aspiration pneumonia and limit the use of noninvasive mechanical ventilation. We reviewed the treatment for sialorrhea in ALS patients that are available at this time, emphasizing pros and cons for each approach. Our purpose is to create a practical tool for the diagnosis, in order to facilitate the quantification and management of sialorrhea in everyday practice.

COVID-19 has high mortality rate mainly stemming from acute respiratory distress leading to respiratory failure (ARF). Aim of the study was to evaluate the management of severe ARF due to COVID-19 pneumonia using noninvasive ventilatory support (NIVS), studying safety and effectiveness of NIVS.This is a retrospective, multicenter study. Primary outcomes were NIVS failure with intubation rate and hospital mortality. Secondary outcomes were hospital stay and factors related to NIVS failure and mortality. These outcomes were compared with patients intubated and admitted to ICU.One hundred sixty-two patients were hospitalized because of severe respiratory failure (PaOinf2/inf/FiOinf2/infratio250). One hundred thirty-eight patients were admitted to Respiratory Intermediate Care Unit (RICU) for a NIVS trial. One hundred patients were treated successfully with NIVS (74.5%); 38 failed NIVS trial (27.5%). In-hospital mortality was 23.18% in RICU group and 30.55% in ICU group. Patients with NIVS failure were older, had a lower number of lymphocytes, a higher IL-6, lower PaOinf2/inf, PaC Oinf2/inf, PaOinf2/inf/FiOinf2/infratio, higher respiratory rate (RR) and heart rate at admission and lower PaO2, and PaOinf2/inf/FiOinf2/infratio and higher RR after 1-6 hours. Multivariate analysis identified higher age, C-reactive protein as well as RR after 1-6 hours and PaOinf2/inf/FiOinf2/infratio after 1-6 hours as an independent predictor mortality.NIVS is a safe and effective strategy in the treatment of severe ARF due to COVID-19 related pneumonia, that reduces mortality and length of hospital stay in the carefully selected patients.

Background Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease affecting upper and lower motor neurons and resulting in progressive skeletal muscle weakness. Weak cough and difficulty in clearing secretions are often the cause of pulmonary infections and acute respiratory failure. Cough assistance is commonly used to provide support in coughing for patients with ALS. Methods This was a preliminary parallel randomized study comparing two cough-assist devices: one utilizing mechanical insufflation/exsufflation (MI/E) and expiratory flow accelerator (EFA) technology, the other utilizing only MI/E technology. The aim was to compare the effectiveness, safety and acceptability of the two devices. Thirty patients with ALS and similar severity and functional scale were enrolled. The primary outcome was the change in respiratory function, respiratory muscle function, gas exchange, and peak cough expiratory flow as an indicator of cough efficacy. Secondary outcomes were the number of exacerbations at 1, 6 and 12 months of treatment, and the patient-perceived comfort/distress related to the interventions together with the perceived efficacy of cough. Results 30 subjects were recruited and randomized into the two groups (1:1 ratio). Primary outcomes: Respiratory function parameters decreased over time in both groups, but significantly less in the Kalos group, as did the respiratory muscle strength parameters and peak cough flows. Gas exchanges decreased over time in both groups with no clinically relevant differences between groups. Secondary outcomes there were no significant differences between groups regarding the number of exacerbations over time. No adverse events were reported. All participants, in both groups, reported a similar increase in perceived cough efficacy and there was no significant difference in comfort and distress between the two treatments. Conclusions The cough-assist device with EFA technology performed better than a traditional MI/E device in ALS patients regarding respiratory function and cough efficacy, although number of exacerbations and acceptability of the two devices was similar. Following these promising preliminary results, further investigation is required in a larger cohort to confirm the superiority of EFA technology associated with a MI/E device.

Introduction Pneumonia is both the most common type of lower respiratory tract infection and a major cause of morbidity and mortality worldwide. The COVID-19 pandemic caused by the SARS-CoV-2 raised an extremely serious concern, because its most frequent clinical presentation was pneumonia. Features such as sex play an active role in the incidence and outcomes of pneumonia. This study aimed to evaluate differences between sexes concerning COVID-19-related pneumonia. Methods This was a retrospective, multicentre study that enrolled 340 consecutive adult patients admitted to hospital for COVID-19-related pneumonia. Of these patients, 219 were males (64.4%) and 121, females (35.6%). Primary endpoints were differences between both sexes as per clinical features, laboratory and radiologic results, and inhospital and 30-day mortality. Secondary outcomes included differences between both sexes and factors associated with mortality. Results Males admitted to the COVID-19 Unit were older than females (74.5 ± 15.7 vs. 64.5 ± 11.9). Cardiovascular disorders were more frequent in males (19.17% vs 13.25%), whereas obesity was more common in females (54.5% vs 37.45%). In-hospital and 30-day mortality were higher in males than in females (23.3% vs 15.7%; 24.6% vs 19.8%, respectively). No differences were observed in hospital stay; however, males had a longer ICU stay when compared with females (11.04±5.4 vs 7.05±3.4). Variables associated with a higher mortality rate included older age, a lower number of lymphocytes upon admission and higher levels of ferritin and troponin upon admission. Conclusions Males had significantly higher mortality and longer ICU stay than females. More comorbidities in males than in females could explain the difference in mortality rates. The protective role of genetic factors can partially explain the better outcomes observed in female patients with COVID-19.

Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, “(secretion OR secretions) AND (noninvasive ventilation OR NIV)” on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel’s suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel’s suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.

We studied 33 patients affected by juvenile and adult myotonic dystrophy type 1 (DM1). The aim of the study was to assess clinical and laboratory parameters that could predict the requirement of noninvasive ventilation (NIV) in DM1. Secondary outcome was to assess the interplay between genetic profile, muscle impairment severity and presence of cardiac comorbidities.Patients with genetic diagnosis of DM1 were recruited. An abnormal trinucleotide repeat (CTG) expansion of dystrophy protein kinase gene (DMPK) on chromosome 19q13.3 was the prerequisite for inclusion. The number of triplet repeats was measured in genomic DNA to classify subjects. A multidisciplinary team evaluated the patients every 6-8 months up to 18 years with serial cardiological and respiratory function assessments. Neurological progression was monitored using a validated DM1-specific rating scale (MIRS). Independent variables considered for the study outcomes were gender, genetic status, age of presentation, MIRS scores, and results of pulmonary function tests (PFTs).Patients were 17 males (51.5%) and 16 females (48.5%). 16 cases were younger than mean age of 31.4 years, the remaining 17 were up to 65. 12 subjects (36.4%) underwent NIV during follow up. Cardiac comorbidities were detected in 63.6% of cases and in 91% of patients in NIV. Among PFTs, forced vital capacity (FVC) was a reliable indicator of respiratory decline. FVC values were significantly associated with clinical muscle severity assessed by MIRS.Severity of muscular impairment, CTG expansion size, age and presence of cardiac comorbidities predict respiratory impairment in DM1.

Objective: In the last two decades many reports demonstrated the unreliability of endometrial biopsy pathology showing an AH (Atypical Hyperplasia) to exclude a synchronous EEC (Endometrioid Endometrial Carcinoma), with an underestimation of EEC in up to 50% of women. Hysteroscopy is now considered the standard diagnostic tool for endometrial pathology. However, a recent meta-analysis showed that hysteroscopically-guided biopsy provides a high rate of failure with respect to dilatation and curettage (D&C) and endometrial resection, in underestimating AH instead of concurrent EC. The aim of this study was to assess the sensitivity of hysteroscopy-view and hysteroscopic sampling in diagnosing EEC. Materials and Methods: A multicenter, retrospective, observational trial was conducted between January 2012 and December 2018 in 14 Italian Gynecological Units (University-affiliated or Public Hospitals). Eligible patients were identified as those women in whom either a pathologic report of EEC was found on hysterectomy specimen and a preoperative hysteroscopy assessment with endometrial biopsy targeted under vision had been performed. As primary outcome we calculated the sensitivity of hysteroscopy-view and biopsy pathology on hysteroscopically-driven sampling in the diagnostic work-up of EC. Results: 948 patients (age 65,83±10,43) resulted eligible for analysis. Hysteroscopy-view showed a sensitivity of 54.2%, specificity 47,2% and accuracy 54% in the diagnosis of EC. Moreover, hysteroscopic view was significantly able to distinguish carcinoma from hyperplasia (p

Cerebral palsy (CP) is a condition that can occur at any time during brain development. Although its etiology is multifactorial, CP is usually linked to brain injury or infections during prenatal, perinatal, neonatal or early childhood period. The disability associated with CP varies from mild to severe, and may include involuntary movements, poor coordination, maintaining balance problems and the difficulty of performing voluntary movements. Although this condition (brain impairment) does not directly cause pulmonary complications, neuromuscular dysfunctions do so. In fact, aspiration and ineffective coughing could interfere with normal airway clearance, impair respiratory function, and worsen lung damage, resulting in increased mucus production and reduced secretions elimination. This consequent alteration of the pulmonary defense system increases the susceptibility to serious, progressive lung diseases. Physiotherapy is an essential component in the management of respiratory complications associated with severe CP. For optimal results, however, it is important customized treatment for every patient. This mini non-ystematic review would highlight the possible complications and the possible interventions for reduce them.

Objective In the last two decades, many reports demonstrated the unreliability of endometrial biopsy pathology showing an AH (atypical hyperplasia) to exclude a synchronous EEC (endometrioid endometrial carcinoma), with an underestimation of EEC in up to 50% of women. Hysteroscopy is now considered the standard diagnostic tool for endometrial pathology. However, a recent meta-analysis showed that hysteroscopically guided biopsy provides a high rate of failure with respect to dilatation and curettage (D&C) and endometrial resection, in underestimating AH instead of concurrent EC. The aim of this study was to assess the sensitivity of hysteroscopy view and hysteroscopic sampling in diagnosing EEC. Materials and methods A multicenter, retrospective, observational trial was conducted between January 2012 and December 2018 in 14 Italian gynecological units (university-affiliated or public hospitals). Eligible patients were identified as those women in whom either a pathologic report of EEC was found on hysterectomy specimen and a preoperative hysteroscopy assessment with endometrial biopsy targeted under vision had been performed. As primary outcome, we calculated the sensitivity of hysteroscopy view and biopsy pathology on hysteroscopically driven sampling in the diagnostic workup of EC. Results Nine hundred forty-eight patients (age 65.83 ± 10.43) resulted eligible for analysis. Hysteroscopy view showed a sensitivity of 54.2%, a specificity of 47.2%, and an accuracy of 54% in the diagnosis of EC. Moreover, hysteroscopic view was significantly able to distinguish carcinoma from hyperplasia (p < 0.001). We evidenced an important difference of the results comparing the centers involved. Hysteroscopy-driven biopsy presented a sensitivity of 76.2%, a specificity of 52.8%, and an accuracy of 75.3%. AH pathology was reported in 19% of the cases. Conclusion Our study showed that EEC diagnosis via hysteroscopy diagnosis could be improved through the implementation of operator training. Hysteroscopy-driven biopsies have excellent sensitivity and accuracy in the diagnosis of EEC, and the advantages of using hysteroscopy for making a diagnosis can improve the management of the patients with EEC. While it seems reasonable that hysteroscopy is the preferred technique for diagnosing and treating a benign pathology of the uterus, it could play a major role even in the diagnosis of a malignancy.

Not available

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of the motor neuron, which selectively affects it both at central (first motor-neuron) and peripheral level (second motor-neuron). The disease shows up at a mean age of 56 years and the most affected are males. Although ALS may start as a bulbar or spinal disease, with the progression of the disease typically both become evident. Pharmacological approved treatments for ALS are still limited and include riluzole and edaravone which improve survival over time. Despite this, ALS leads to progressive muscle involvement and requires a complex multidisciplinary approach to manage increasing disability which goes beyond motor neurons. Sialorrhea is, amongst others, one of the most disabling symptoms in ALS. The complexity in managing saliva is due to a muscular spasticity and to a scarce palatino-lingual muscles control, rather than to an overproduction of saliva. These features could increase the risk of aspiration pneumonia and limit the use of noninvasive mechanical ventilation. We reviewed the treatment for sialorrhea in ALS patients that are available at this time, emphasizing pros and cons for each approach. Our purpose is to create a practical tool for the diagnosis, in order to facilitate the quantification and management of sialorrhea in everyday practice.

Background: Kyphoscoliosis is a skeletal condition involving the hyperflexion of the thoracic spine. It is characterized by reduced chest wall compliance and impaired respiratory mechanisms leading to progressive hypo-ventilation. We evaluated the effectiveness and the safety of non-invasive ventilation (NIV) in patients after an episode of acute respiratory failure (ARF). Methods: Eighteen patients with severe kyphoscoliosis who had been hospitalized for an episode of ARF were followed for 4 years. NIV was applied via mouthpiece (MPV) during the daytime and via mask during the night. The primary outcomes were changes in physiological and functional parameters as well as quality of life. Secondary outcomes were considered re-hospitalization and mortality rate after discharge. A set of control subjects was used for comparison. Results: All patients showed a significant improvement in several clinical, physiological, functional and quality of life parameters. Four of them (22.2%) died during the four year follow-up period. In the uni-variate analysis patients who died had higher cardiac co-morbidity, lower MIP and SNIP, higher paCO2, and oxygen desaturation index at initial admission. Conclusions: Diurnal MPV associated with nocturnal NIV had significantly improved lung function, clinical outcomes and quality of life. It should be considered as a safe alternative to traditional administering of NIV. Keywords: Kyphoscoliosis, Respiratory failure, Non-invasive ventilation, Mouthpiece ventilation

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries. info:eu-repo/semantics/publishedVersion

STUDY OBJECTIVE To compare the effectiveness and safety of different techniques of hysteroscopic polypectomy. DESIGN Multicenter, prospective observational trial (Canadian Task Force classification II-2). SETTING Nineteen Italian gynecologic departments (university-affiliated or public hospitals). PATIENTS Consecutive patients suffering from endometrial polyps (EPs). INTERVENTIONS Hysteroscopic polypectomy, as performed through different techniques. MEASUREMENTS AND MAIN RESULTS Included in the study were 1404 patients (with 1825 EPs). The setting was an ambulatory care unit in 40.38% of the cases (567 women), of whom 97.7% (554) did not require analgesia/anesthesia. In the remaining 59.62% of women (837 women), the procedures were performed in an operating room under mild sedation, local or general anesthesia. Minor complications occurred in 32 patients (2.27%), without significant differences between the techniques used (p = ns). Uterine perforation occurred in 14 cases, all performed in the operating room with some kind of anesthesia, only 1 with a vaginoscopic technique and the remaining during blind dilatation (odds ratio [OR], 19.98; 95% confidence interval [CI], 1.19-335.79; p = .04). An incomplete removal of EPs was documented in 39 patients. Logistic regression analysis showed that a higher risk of residual EPs was associated with the use of a fiber-based 3.5-mm hysteroscope (OR, 6.78; 95% CI, 2.97-15.52; p

Objectives Chronic obstructive pulmonary disease (COPD) is associated with a higher risk of pulmonary infections. This risk not only negatively affects patients' quality of life but also increases social and health costs. Hence, there is a need for an effective rehabilitative treatment including airway clearance. The aim of this pilot study was to evaluate the efficacy of a new tool for bronchial clearance based on expiratory flow accelerator (EFA) technology compared with positive expiratory pressure (PEP) treatment. Materials and methods Twenty stable patients with COPD, Global Initiative for Chronic Obstructive Lung Disease 3-4 stage, were enrolled and allocated to treatment with EFA or Bubble-PEP (BP) for 20 days during a pulmonary rehabilitation program. At baseline and the end of treatment, the following parameters were measured: arterial blood gases (ABG); respiratory function, including peak cough expiratory flow (PCEF), maximal inspiratory pressure (MIP), and maximal expiratory pressure exercise capacity using the 6-minute walk test (6MWT), dyspnea using the Medical Research Council scale, and quality of life using the St. George's Respiratory Questionnaire. Results Expiratory flow accelerator showed a significant pre- and post-improvement in ABG and a significantly greater improvement than BP in PCEF, MIP, and 6MWT post-treatment. Conclusion Expiratory flow accelerator is a valid device compared with BP as an adjunctive therapy for the treatment of patients with severe COPD.

In 2013 new âmouthpiece ventilationâ modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via âmaskâ interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22 mm angled mouthpieces and straw-type mouthpieces are the most commonly used.NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates âair-stackingâ to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV. Resumo: Em 2013, foram introduzidos novos modos de «ventilação por peça bucal», para ventiladores portáteis disponíveis comercialmente. Apesar disto, há pouco conhecimento sobre como usar a ventilação não invasiva por pressão positiva intermitente (NIV) em oposição à pressão positiva bi-nível (PAP) e ambas têm sido referidas, quase exclusivamente, como sendo utilizadas através de interfaces nasais ou oro-nasais, em vez de através de uma simples peça bucal.à referido com frequência a falência da ventilação não invasiva, devido à acumulação de secreções nas vias respiratórias, devido à hipercapnia por deficiente ajuste dos parâmetros da PAP ou devido a uma reduzida tolerância à interface. Esta última pode ser causada por fatores como pressão excessiva na face devido a um ajuste defeituoso, fuga excessiva de ar pela boca, ansiedade, claustrofobia e falta de sincronia entre o doente e o ventilador. Deste modo, a interface tem um papel crucial na tolerância e eficácia. Interfaces que cobrem o nariz e/ou a boca (oro-nasal) são as mais habitualmente usadas, mas são as que apresentam maior propensão a provocarem lesões na pele e claustrofobia. A maioria dos inconvenientes associados pode ser evitada usando VNI por bocal. A VNI de circuito aberto por peça bucal está a ser usada por um número significativo de doentes em alguns centros, na assistência ventilatória diurna e como complemento da VNI noturna através de «máscara». A VNI por peça bucal é igualmente utilizada durante o sono com o bucal fixo na posição, através de uma orla de cobertura do lábio. As peças bucais mais utilizadas são as pequenas anguladas de 15 e 22 mm e as de tipo «palhinha».A VNI através de de peça bucal é usada por um número significativo de doentes como uma alternativa eficaz à ventilação assistida através de tubo de traqueostomia (VTM) e está associada à redução do risco de pneumonias e outras complicações respiratórias. A sua utilização facilita a «acumulação de ar» que aumenta a eficácia da tosse, o discurso e a compliance pulmonar, melhorando a qualidade de vida dos doentes com doenças neuromusculares (DNM) em comparação as alternativas invasivas. Considerando estes benefícios e a disponibilização de modos ventilatórios NIV por peça bucal, é agora garantido um maior conhecimento desta técnica. Esta revisão destaca as indicações, técnicas, vantagens e desvantagens do VNI por peça bucal. Keywords: Noninvasive ventilation, Mouthpiece, Open-circuit mouthpiece ventilation, Neuromuscular disease, Ventilator settings, Palavras-chave: Ventilação não invasiva, Peça Bucal, Ventilação por peça bucal de circuito aberto, Doença neuromuscular, Parâmetros do ventilador

We investigated the feasibility and acceptability of office hysteroscopic polypectomy using a new continuous-flow operative 16 Fr Gubbini’s mini-resectoscope. This is a prospective clinical study (Canadian Task Force classification III). The office hysteroscopic polypectomy was performed with a mini-resectoscope without analgesia or anesthesia. We evaluated the polyp size and the number, the effectiveness of resection, the operating time, the pelvic pain and complications. The office hysteroscopic polypectomy was successfully performed in all 33 patients. The polyps ranged in size from 5 to 50 mm with a mean of 18.15 ± 11.45 mm. We analyzed the operating time with a mean of 11.45 ± 4.71 min: 29 procedures took less than 15 min from the start of vaginoscopy to the end of surgery. Overall mean visual analog scale (VAS) calculated was 2.48 ± 1.37 (range 0–6). The correlation between the size of the polyps and operating time was statistically significant (p

Dear EditorPoor prognosis in amyotrophic lateral sclerosis (ALS) is primarily caused by the development of acute respiratory failure (ARF). Despite the recent proposal of a scoring system for early...

Bipolar technology was introduced in the hysteroscopic clinical use in 1999, by the design of both loop electrodes addressed to resectoscopic surgery and miniaturized electrodes adaptable to small-size hysteroscopes. The need of an electrolytic solution as distension medium and the spatial relationships between the active and return bipolar electrode avoid, by definition, the risks of severe electrolyte imbalance syndromes and unpredictable electrical burns, sometimes complicating monopolar surgery. The true revolution in the hysteroscopy care has achieved through the availability of mini-hysteroscopes not requiring cervical dilatation, thus limiting uterine wall damages and allowing surgeons to manage several endometrial pathologies by mini-invasive procedures using an effective electrosurgical bipolar instrumentation. Many surgical interventions, traditionally accomplished by the resectoscope in a surgical room theatre, can be now carried out in an outpatient setting without any support from anesthesia. The patients' avoidance of surgical room access and the quick return to daily activities lead to an obvious - but not fully demonstrated - improvement in the medical and social costs associated to outpatient operative hysteroscopy. In the field of resectoscopy, bipolar electrodes are clinically as effective as monopolar devices. Randomized trials showed that bipolar resectoscopic technology prevents the electrolyte imbalance observed after monopolar surgery. However, in daily clinical practice the assumedly safer profile of bipolar with respect to monopolar resectoscopy has not been demonstrated yet.

Dear EditorThe article of Thompson et al. (1) is certainly interesting, because for the first time it tries to stratify the risk of patient safe late-stage SLA in amyotrophic lateral sclerosis (ALS...

Bipolar technology was introduced in the hysteroscopy field with resectoscopic loops and electrodes adaptable to mini-hysteroscopes. The use of isotonic saline as a distension medium and the proximity of electrodes reduce the risk of electrolyte imbalance and electrical burns. Delivering an electrosurgical device throughout mini-hysteroscopes avoids cervical dilatation, limiting uterine wall damages. The feasibility of outpatient interventions improves clinical outcomes and medical costs avoiding general anaesthesia. This review updates clinical experiences based on bipolar technology and evaluates whether it represents a reliable improvement in operative hysteroscopy.Bipolar and monopolar resectoscopic loops were compared in one randomized study, showing similar efficacy and safety. Inpatient mini-hysteroscopy by microelectrodes is effective in interventions usually accomplished by resectoscope. In one randomized study, bipolar metroplasty proved to be safer and more effective than resectoscopy. Outpatient operative hysteroscopy is a developing field and retrospective reports demonstrate its effectiveness and safety. No randomized studies assessed the clinical and economical improvements of office procedures with respect to resectoscopy.Safety and efficacy of bipolar surgery, with respect to monopolar instrumentation, is an assumption to be demonstrated. The main evolution derived from introduction of bipolar devices is probably represented by a safe shifting of inpatient procedures to the office, leading to saving of medical costs. In this field, evidence-based answers are required.

Uterine tumors resembling ovarian sex cord tumors (UTROSCTs) are rare neoplasms of uncertain malignancy, affecting either pre or menopausal women. Only 48 cases of UTROSCTs have been reported and in most patients the diagnosis was made incidentally, after a hysterectomy as a result of the assumption of a leiomyoma. Although no death from progressive disease was reported, locoregional spread or abdominal relapse was detected in some patients. Up until now, a treatment sparing the uterus was reported in only 2 patients with UTROSCTs. Both patients conceived after surgery and were free from recurrent disease after a mean follow-up of 16.5 months. We report a third case of a young patient affected by pure UTROSCTs and treated conservatively. A 29-year-old woman underwent resectoscopic hysteroscopy because of the assumption of a grade-1 submucous myoma measuring about 5 cm. To accomplish the removal of the endometrial mass, a 2-step hysteroscopic resection was required. Histology showed epithelioid cells arranged in nests, cords, tubules, and trabeculae infiltrating the myometrium; no sarcoma cell differentiation was detected. Immunohistochemistry resulted in positivity to CD99, inhibin, calretinin, cytokeratin, and estrogen receptor, whereas a negative staining to epithelial membrane antigen, actin, desmin, and human melanoma black 45 was obtained. Based on histologic pattern and immunohistochemical phenotype, a diagnosis of pure UTROSCTs was made; the staging of disease revealed neither locoregional spread nor distant metastases. Two months after surgery, reassessment by hysteroscopy and endometrial biopsy revealed no residual endometrial disease. The patient was free from disease 13 months after surgery. Because of the uncertain malignant potential of UTROSCTs and based on the poor data available from current literature, a fertility-sparing surgery in young patients appears safe. However, a close long-term follow-up is required and a quick completion of a patient's childbearing desire seems advisable.

Study Objective Comparison of operating outcomes of office hysteroscopic polypectomy accomplished by mechanical or bipolar electrosurgical instrumentation. Design Prospective study (Canadian Task Force classification II-1). Setting Public hospital. Patients A total of 101 consecutive postmenopausal patients showing, during office hysteroscopy, 1 or more endometrial polyps measuring more than .5 cm. Interventions Hysteroscopy was carried out with a 2.9-mm optic and a 3.9- × 5.9-mm sheathed operative hysteroscope, without local anesthesia or systemic analgesia. The diagnostic phase was immediately followed by polyp resection, alternatively allocating the patients to mechanical or electrosurgical polypectomy. Hysteroscopic scissors were used for mechanical polypectomy, whereas 5F coaxial bipolar twizzle electrodes were used for electrosurgical polypectomy. Measurements and Main Results Effectiveness of polypectomy, operation time, and evaluation of induced pelvic pain (scored on a 1–10 cm visual analog scale), were the end points of comparison between the 2 techniques. Nine patients were excluded because of severe pelvic pain arising in the diagnostic phase or the finding of an oversize polyp requiring an estimated time of more than 30 minutes to be removed in the office setting. Of the remaining 92 patients, 46 underwent mechanical and 46 electrosurgical polypectomy. Clinical variables (i.e., age, age at menopause, parity, polyp size, and number) were similar in the 2 study arms. Polypectomy was accomplished in 79 (85.8%) of 92 patients. Among the considered clinical variables, effectiveness of resection was significantly related to age of patients (p = .04) and polyp size (p = .004). Mechanical and electrosurgical polypectomy was completed in 37 (80.4%) of 46 patients and in 42 (91.3%) of 46 patients, respectively (p = .13). Furthermore, mechanical and electrosurgical resections did not significantly differ as regards median surgical time (15.0 min [range 5–45] and 15.5 min [range 8–40], respectively; p = .53) and visual analog scale scores (3.7 ± 2.5 and 3.2 ± 1.9, respectively; p = .48). No major complications were recorded. Atypical polyp histology occurred in 9 (8.8%) patients, 5 of whom were asymptomatic. Conclusion Outpatient see-and-treat polypectomy represents a safe and effective alternative to resectoscopic polypectomy, leading to a complete polyp excision in about 80% of postmenopausal patients. No differences in the rate of polyp excision, surgical time, or induced pelvic discomfort were observed between electrosurgical and mechanical techniques.

Chronic obstructive pulmonary disease (COPD) is associated with a 2-3 times higher rate of cardiovascular disorders (CVD) which is independent of other risk factors. A low FEV1 is a specific predictor of mortality as a result of cardiac causes, even stronger than increased cholesterol: for each 10% reduction of FEV1, cardiovascular mortality increases by 28%. The main causes of death among COPD patients are of cardiovascular origin. COPD and CVD have two major risk factors in common - advanced age and tobacco smoking. The search for a pathogenetic link between the two conditions focuses mainly on systemic extension of pulmonary inflammation. Despite such a frequent association, pulmonologists and cardiologists in both the clinical and the research settings often underestimate the importance of a correct diagnosis and severity stratification of the two combined conditions. Spirometry, in particular, is largely underprescribed. Missed diagnosis and severity stratification, incomplete knowledge of adverse drug events and lack of resources lead to undertreatment of patients combining COPD and CVD, and in particular, the underuse of beta-blockers, inhaled bronchodilators and rehabilitation. Clinical studies focusing on this group of patients should be promoted in the future to test therapies and manage options. Furthermore, efforts must be made to improve the present standards of care, which falls short of recommended levels, starting from the often-neglected use of spirometry to confirm a diagnosis of COPD.

Background and Aim. Acute respiratory failure (ARF) is a condition that must be treated as quickly as possible. Continuous Positive Airway Pressure (CPAP) is a common method used to treat ARF in hospital. The main objective of our study was to investigate the effect of CPAP prior to admission to the emergency room, on the reduction of endotracheal intubation, in-hospital mortality and on the length of stay in hospital (HLOS). Methods. A prospective, observational (non-randomised) study with a historical control group. Data from 3 groups of patients with ARF, irrespective of cause, was collected: pre-hospital CPAP (PHCPAP) group, i.e. 35 patients treated with a helmet CPAP in the ambulance, by trained nurses (mean age, years 80.1±7.9 SD; 14 males); hospital CPAP (HCPAP) group, i.e. 46 patients treated with helmet CPAP in the hospital emergency room (mean age 78.6±6.9 SD; 27 males), and a historical control group of 125 patients treated with medical therapy only (mean age 76.7±5.5 SD; 52 males). CPAP was delivered via a helmet interface. Results. Compared with standard medical therapy, helmet CPAP (pre and in-hospital) reduced mortality by 77 % (p=0.005), while pre-hospital helmet CPAP reduced it by 94% (p=0.011), after adjustment for age, sex, severity of clinical conditions at entry and diagnosis upon admission. HLOS was reduced, compared with standard medical therapy, by 63.5% and by 66% (adjusting for age, sex, severity of clinical conditions at entry and diagnosis at admission) with helmet CPAP (pre and in-hospital) and with helmet CPAP in the ambulance, respectively (p

Background Management of secretions in children with cerebral palsy is often problematic due to severe deformation of the rib cage, impaired cough, and patients’inability to collaborate with chest physiotherapy. Assessing the effectiveness of different methods and techniques of secretion clearance is hampered by the lack of direct outcome measures and by limited patient cooperation. This observational study was planned to evaluate the efficacy of Free Aspire, a device that utilizes a special method to remove secretions from the bronchial tree in hypersecretive patients. Case presentation Cerebral palsy patients were selected who had experienced more than 3 episodes of respiratory exacerbations in the latest year despite therapeutic optimization (including bronchial clearance techniques) and who had received at least one antibiotic course or underwent at least one access to the Emergency Room (ER) or admission to hospital in the 6 months prior to the study. Patients with congestive heart failure or contraindications for Free Aspire were excluded. We prospectively enrolled 8 patients (mean age 8.25 ± 6.11 years) who had been using in the past techniques for clearance secretions different from Free Aspire. The treatment with Free Aspire consisted of at least two 20-min sessions per day. The observational study period was 18 months. In the 6 months prior to start the treatment (T0), patients had a mean number of 4.0 ± 2.23 visits from the primary care pediatrician (PCP), spent 14 ± 20 days in hospital, and received antibiotics for 35 ± 17 days. After the first 6 months of treatment (T1), they had 1.7 ± 0.73 PCP visits, no days spent in hospital, and 9.75 ± 10.4 days of antibiotic therapy. At 12 months of treatment (T2), PCP visits were 1.7 ± 0.70, days in hospital 1.12 ± 0.3, and days of antibiotics 10.25 ± 10. At 18 months of treatment (T3) no hospitalizations had occurred, PCP visits were 0.25 ± 0.70, and days of antibiotic therapy 4.8 ± 12.62. The technique proved to be safe and well tolerated. Conclusion Our findings show that Free Aspire for bronchial secretion clearance in cerebral palsy patients with limited capacity to collaborate is safe and effective in reducing the impact of respiratory exacerbations in terms of number of PCP visits, days spent in hospital, and days of antibiotic therapy; its regular use maintains this effect in time.

Study objective To evaluate whether hysteroscopic imaging can contribute to decrease the rate of undetected endometrial carcinomas concurrent with atypical hyperplasia diagnosed by endometrial biopsy. Design Retrospective study. Design Classification Canadian Task Force Classification II-3. Setting Public hospital. Patients Hysteroscopic reports of 25 menopausal patients undergoing endometrial biopsy yielding a diagnosis of atypical hyperplasia were reviewed. On the basis of this diagnosis, all patients were treated by hysterectomy, and the pathologic findings on the uterine specimen were correlated with the diagnoses obtained by hysteroscopic view. Interventions Hysteroscopy was video-assisted and carried out with normal saline solution used as liquid distension medium; a 5-mm sheathed hysteroscope, with a working channel, was used for each examination. After hysteroscopic inspection, an endometrial sampling targeted under vision was performed by mechanical or electrosurgical instrumentation. When extensive features of hyperplastic or neoplastic growth were observed, we combined a blind sampling procedure with Vabra-curettage. We calculated the sensitivity, specificity, and negative and positive predictive values of hysteroscopic inspection to foresee the diagnosis of endometrial cancer incidentally detected on hysterectomy specimen. Measurements and main results On the basis of histopathologic study of uterine specimens, non atypical hyperplasias were detected in 3 patients, the diagnosis of complex atypical hyperplasia was confirmed in 11 patients, whereas a concurrent infiltrating endometrial adenocarcinoma was detected in 11 patients (44.0%). In the 14 patients with diagnosis of endometrial hyperplasia, no feature suggesting endometrial malignancy was reported by hysteroscopic inspection. In the 11 cases showing infiltrating carcinomas, hysteroscopic view was consistent with endometrial malignancy in 9 patients and with endometrial hyperplasia in 2 patients. An intramucous endometrial carcinoma without evidence of myometrial invasion was found on hysterectomy specimens of these two latter patients. From these figures, sensitivity, specificity, and negative and positive predictive values of hysteroscopy to foresee a diagnosis of infiltrating carcinoma were 84.6%, 100%, 87.5%, and 100%, respectively. Conclusions Hysteroscopic view is a sensitive and specific method to identify among patients with a diagnosis of atypical hyperplasia on endometrial biopsy those with a coexisting infiltrating carcinoma.

Objective. The purpose of the present study is to prospectively evaluate the effects of tamoxifen on the pathological behavior of endometrial hyperplasias without atypia, diagnosed before the start of adjuvant endocrine therapy, in menopausal patients suffering from breast cancer. Methods. Twenty-six patients suffering from estrogen–receptor positive breast cancer and candidate to receive adjuvant tamoxifen, were found to be affected by endometrial hyperplasias before the start of endocrine therapy. All women showed a baseline endometrial stripe, measured by transvaginal ultrasonography, thicker than 4 mm and the diagnosis of endometrial hyperplasia was made by hysteroscopy and endometrial biopsy. Two patients showing complex atypical hyperplasia underwent vaginal hysterectomy, whereas the remaining 24 patients, suffering from endometrial hyperplasia without atypia, were followed on a yearly basis during the period of tamoxifen intake, by hysteroscopy and endometrial biopsy. Results. Baseline histopathology showed simple and complex hyperplasia in 20 and in 4 patients, respectively. The median follow-up period was 38 months; in particular, all patients underwent endometrial assessment after 12 months, while 22, 16, 10 and 4 patients were followed-up after 24, 36, 48 and 60 months of tamoxifen therapy, respectively. Progression from complex hyperplasia to complex atypical hyperplasia (1 patient) and from complex and simple hyperplasia to adenocarcinomas (2 patients) was found within 24 months of tamoxifen intake in 3 patients (12.5%). In 2 patients (8.3%), a progression from simple to complex hyperplasia was detected within 36 months of tamoxifen treatment. In 13 patients (54.1%), stable histology of simple or complex hyperplasia was found, whereas 6 patients (25.0%), with focal hyperplasia harbored in an endometrial polyp, showed a normalization of endometrial histology after polyp resection. Conclusions. Endometrial hyperplasias without atypia diagnosed before endocrine therapy for breast cancer in menopausal patients show an early and high progression-rate to atypical lesions under tamoxifen influence.

Objective . The aim of this study is to estimate the prevalence of endometrial pathology before the start of tamoxifen therapy in menopausal breast cancer patients. Methods . Ninety-one gynecologically asymptomatic patients, suffering from estrogen receptor-positive breast cancer and scheduled for adjuvant tamoxifen, underwent pretreatment endometrial assessment. In all patients, a transvaginal ultrasonography was carried out; a double-layered endometrial stripe measuring above 4 mm was considered as abnormal. In these patients, outpatient hysteroscopy and endometrial biopsy were performed. Pathologic findings were considered the reference test in estimating the prevalence of endometrial morbidity. Results . In 34 patients (37.3%) a thickened endometrium was an indication for hysteroscopic and pathologic assessment. Endometrial polyps, simple hyperplasias, and complex atypical hyperplasias were found in 10 (10.9%), 4 (4.3%), and 3 (3.2%) patients, respectively, leading to an overall prevalence of baseline endometrial morbidity of 18.6%. Established individual risk factors for development of endometrial pathology, such as body mass index, age at menarche and menopause, and parity, did not significantly differ in patients with and without endometrial abnormalities. Only patients' age (63.8 ± 8.6 and 52.2 ± 11.8; P = 0.03) and endometrial thickness (10.5 ± 3.5 and 3.9 ± 3.0; P > 0.001) were significant predictive factors of endometrial pathology. Conclusions . Menopausal women with estrogen receptor-positive breast cancer appear to have high risk of baseline subclinical endometrial abnormalities; therefore, an endometrial assessment, before the start of tamoxifen therapy, is always recommended in such patients.

Study Objective To evaluate the feasibility of a “see-and-treat” office polyp resection, using a 5-mm sheathed operative hysteroscope. Design Retrospective study (Canadian Task Force classification II-2). Setting Public hospital. Patients Two hundred thirty-seven patients suffering from endometrial polyps who underwent outpatient hysteroscopy. Interventions Office polypectomy with anesthetic paracervical block (120 patients) or without (117 patients) using either mechanical (104 patients) or bipolar coaxial electrosurgical (107 patients) instrumentation. In 26 patients, we stopped the procedure before surgery because of intervening adverse events or polyps judged unresectable with an office-based procedure. A 10-cm visual analog scale (VAS) was used to rate patients' pelvic pain perception. Measurements and Main Results Overall effective polyp resection rate was 81.2% (191 of 235 evaluable patients). An inverse, although not significant (r = -.44) correlation was found between accomplished polypectomies and polyp size, ranging from 96.0% to 18.7% when the diameter of polyps was below 1 cm and above 4 cm, respectively (50 of 52 and 3 of 16 successfully accomplished procedures, respectively). No significant differences were found between successful resection rates (83.3% and 80.2%, respectively; p = .10) and VAS scores (2.2 ± 2.6 and 3.6 ± 2.9, respectively; p = .30) obtained in 79 premenopausal and 156 postmenopausal patients. Paracervical block administration (118 evaluable patients) matched with no anesthetic support (117 patients) was not associated either with an improved rate of resection (85.5% and 76.9%, respectively; p = .10) or with pelvic pain perception (VAS scores 3.3 ± 2.9 and 3.0 ± 2.8, respectively; p = .94). Visual analog scale scores were significantly lower (2.8 ± 2.5 and 4.7 ± 3.6, respectively; p = .001) and polyp resection rates were significantly higher (84.3% and 67.4%, respectively; p = .01) in 192 parous versus 43 nulliparous patients. Polypectomy failed in 44 of 235 patients (18.7%); the leading causes of failure were intolerable pelvic pain in 18 patients (7.6%) and polyp size in 17 patients (7.2%). Other than pelvic pain, the only adverse event we observed was clinical vasovagal reaction in four patients (1.7%). Conclusion One-stop outpatient hysteroscopic polypectomy is effective in about 80% of patients. With proper preoperative selection, it can be offered as a reliable option to avoid general anesthesia and resectoscopic surgery.

Objective. The objective of this study was to compare office feasibility, patient acceptance, and diagnostic accuracy of hysteroscopy (HYS) and saline infusion sonography (SIS) in breast cancer patients taking tamoxifen. Methods. Sixty-six asymptomatic postmenopausal women on tamoxifen for breast cancer underwent SIS, followed by outpatient HYS with endometrial biopsy. In all women an endometrial stripe over 4 mm was previously measured by transvaginal ultrasonography (TU). Histologic reports were matched with sonographic and hysteroscopic findings. After SIS and HYS, patients were asked to rate pelvic pain experienced during the two procedures on a 10 cm Visual Analog Scale (VAS). Results. SIS and HYS were not accomplished in 26 (39.3%) and 4 (6.0%) patients, respectively, due to cervical stenosis or patient intolerance. No adverse event was recorded after 40 SIS and 62 hysteroscopic procedures. Pathologic assessment reported 15 polyps (22.7%), 7 hyperplasias (10.5%), and 2 submucous myomas (3.0%). Sensitivity, specificity, and negative and positive predictive values of SIS in distinguishing between normal and abnormal endometrium were 85.7, 83.3, 93.7, and 66.0%, respectively, whereas HYS provided corresponding values of 100, 94.1, 97.8, and 100%, respectively. No significant difference was found between SIS and HYS in the subjective perception of pelvic pain (VAS scores 3.02 ± 2.8 and 3.82 ± 2.7, respectively). Conclusions. Office hysteroscopy is a safe and conclusive diagnostic tool for endometrial investigation in menopausal women on tamoxifen. It exposes the patients to the same pelvic discomfort as SIS, but has a better feasibility rate and diagnostic accuracy.

The aim of this study is to evaluate the accuracy of hysteroscopy in detecting tamoxifen-associated endometrial morbidity. Ninety-eight menopausal breast cancer patients taking tamoxifen underwent hysteroscopy because of an endometrial thickness above 4 mm measured by Transvaginal Ultrasonography. Thirty-one women recorded uterine bleeding while 67 were asymptomatic. Hysteroscopies with operative facilities were performed, mainly in out-patient setting. Hysteroscopic findings were matched with histopathology derived from various modalities of tissue collection as suction-curettage, oriented-streak curettage, hysteroscopically-targeted biopsies or polypectomies and hysterectomies. Accuracy of hysteroscopy to estimate a normal or abnormal endometrium was calculated. Abnormal endometrium was detected in 35 patients (64.5% in symptomatic and 22.3% in asymptomatic women, P

Safe removal of tracheal cannula is a major goal in the rehabilitation of tracheostomised patients to achieve progressive independence from mechanical support and reduce the risk of respiratory complications. A tracheal cannula may also cause significant discomfort to the patient, making verbal communication difficult. Particularly when cuffed, tracheal cannula reduces the normal movement of the larynx which can further compromise the basic swallowing defect. A close connection between respiratory, phonating, swallowing and feeding abilities to be recovered, implies a strict integration among different professionals of the rehabilitation team. An appropriate management of tracheostomy cannula is closely connected with assessment and treatment of swallowing disorders in order to limit the development of severe pulmonary and nutritional complications, but at present there are no uniform protocols in the scientific literature. Furthermore, several studies report as an essential criterion for decannulation the presence of good patient consciousness, which is often altered in patients with tracheostomy, but a general agreement is lacking.

Acute respiratory failure (ARF) is a common cause of morbidity and mortality in most advanced neuromuscular disorders (NMD). Deterioration of lung function during NMD may have different severity and time course. During slowly progressive neuromuscular disease an acute event can precipitate the respiratory failure, while rapidly progressive NMD may present as ARF at the onset of the disease. During ARF a patient with NMD may be affected by inspiratory muscles weakness responsible for decreased ventilation, expiratory muscles weakness responsible for altered coughing effectiveness, and bulbar involvement responsible for altered swallowing and airway protection. Neuromuscular disorders may also affect central control of breathing, sleep disorder, bones and joints deformities with consequent ventilatory dysfunction. Usually ARF in NMD is prompted by precipitating factors such as upper airways infections, pneumonia, atelectasis etc. It is important to distinguish respiratory failure due to an acute event or to a rapidly progression of underlying conditions to properly allocate the patient in the more appropriate setting of care. Generally, excessive invasiveness of care must be avoided, and a pro-active early rehabilitation program may help early recovery and minimize complications. Mechanical non invasive positive pressure ventilation(NIPPV) combined with mechanically assisted coughing (MAC) has been established as the standard treatment of severe ARF in NMD. Superiority of NIPPV vs invasive mechanical ventilation (MV) was showed in term of lower mortality, treatment failure, duration of ICU in several studies. Home mechanical noninvasive ventilation and MAC may result dramatic reduction in the need for hospitalization and a prolongation of life expectancy of these patients. To avoid the progression of respiratory failure an early identification of respiratory deterioration is needed, as such as prevention of acute episodes. So, especially in the progressive diseases, is very important to monitor respiratory status with periodic lung function tests. Any respiratory tract infection in neuromuscular disease could trigger acute respiratory failure so it is mandatory take any aggressive measures to prevent and treat this complication. Some of principal preventive measures include vaccination against Pneumococcus Pn. and influenza virus, early antibiotic treatment when bacterial infection is suspected, chest physiotherapy for removal airway secretions or mechanical assisted maneuvers to increase cough efficiency. In conclusion, a proactive, preventive approach is the key for optimal management acute respiratory problems in neuromuscular disorders.

BACKGROUND AND OBJECTIVE: Exacerbations of COPD are often characterized by increased mucus production that is difficult to treat and worsens patients' outcome. This study evaluated the efficacy of a chest physiotherapy technique (expiration with the glottis open in the lateral posture, ELTGOL) during acute exacerbations of COPD using as outcome measures sputum volume, length of hospitalization, reduction in dyspnoea (Borg score), improvement in quality of life (assessed by the St George Respiratory Questionnaire) and incidence of COPD exacerbations during follow up. METHODS: The study recruited 59 patients hospitalized for the treatment of acute exacerbation of COPD, who were randomly assigned to a control group and an intervention group. The control group was treated with standard medical therapy while the intervention group was treated with ELTGOL plus medical therapy. A subgroup of patients was followed for 6 months to verify the effects on COPD exacerbations and need for hospitalizations. RESULTS: At the time of hospital discharge there was no significant difference between the two groups in the outcome measures, with the exception of the Borg score, which was significantly improved in the ELTGOL group (4.3 +/- 1.5 in the control group vs 3.0 +/- 1.8 in the ELTGOL group, P = 0.004). After 6 months there was no significant difference in the other measured parameters between a subset of the groups available for follow up. During follow up, the ELTGOL group had numerically fewer exacerbations and less need for hospitalization though differences were not statistically significant. CONCLUSIONS: Chest physiotherapy using the ELTGOL technique has a limited role in patients with mild exacerbation of moderate to severe COPD with a tendency towards fewer exacerbations and hospitalizations.

We investigated the prevalences of human papillomavirus (HPV) of type 6, 11, 16, 18, 31, 33, 35 and 42 in 276 cervical tissue samples biopsied from a group of North-Italian women in which a HPV infection of the cervix had been suspected. The specimens were evaluated by conventional histological examination and by HPV typing, using Southern blot hybridization on the extracted DNA. We related different degrees of squamous cervical dysplasia, showing or not viral cytopathic effects, with the HPV types harboured in the lesions. Significant rising of HPV 16 prevalences was observed proceeding from mild to moderate and to severe dysplasias both in presence (r = 0.9623, P less than 0.01) and in absence (r = 0.879, P less than 0.05) of koilocytosis, while an opposite trend was detected for HPV 6 and 11. In our sampling we did not find HPV 35 DNA sequences; in all occasions HPV 31 was associated with mild dysplasias. The absolute prevalences of types 18, 33 and 42 were generally low (from 2 to 3%); they did not show any association with specific histological damage of the cervix or with significant patterns related with the progression of cervical dysplasia.

Introduction: cesarean scar pregnancy (csP) is a rare but life-threatening condition, due to the risk of uterine rupture or for the development of placenta previa/accreta. the mainstay of management to spare fertility is early diagnosis and pregnancy termination. Although several conservative treatments have been experienced, no consensus on the best therapeutic approach is currently shared. the medical therapy for csP termination is based on systemic or local Methotrexate (MtX) administration. Hysteroscopy allows the precise visualization of placental implantation and it can be used to drive MtX injection selectively within the intervillous placental spaces. this procedure increases drug concentration delivered to the target tissue, potentially improving its therapeutic index. case report: A 36-year-old female with a history of cesarean section was admitted to our department with a diagnosis of viable 7th weeks csP. the patient gave her consent to pregnancy termination by a hysteroscopically-guided MtX administration within the cervico-isthmic placental implantation site, followed by its resectoscopic removal. In an office setting, 80 mg of MtX were injected through a needle adaptable to the 5-Fr operative channel of hysteroscope, Giancarlo Garuti1, Stefania Calabrese1, Lorenzo Quirino1, Marco Di Mario1 Affiliations: 1MD, Obstetrics and Gynecology Department, Public Hospital of Lodi, Via Savoia 1, 26900-Lodi, Italy. Corresponding Author: Giancarlo Garuti (MD), Obstetrics and Gynecology Department, Lodi Hospital, via Savoia n° 1, 26900-Lodi, Italy; E-mail: giancarlo.garuti@tiscali.it Received: 03 October 2015 Accepted: 02 December 2015 Published: 27 February 2016 under the chorionic membrane of placental implantation site. the duration of the procedure took three minutes and it resulted easy, painless and uneventful. An early embryo demise was obtained; the human chorionic gonadotropinbeta subunit (beta-hcG) serum trend showed a rapid pregnancy termination and no patient complaints were recorded. After 28 days, a resectoscopic removal of the gestational sac and placenta was safely accomplished. conclusion: selective hysteroscopic administration of MtX within intervillous spaces of the ectopic placental implantation is effective and it can be considered for csP termination.