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Objective: To assess individual variation in anxiety, stress disorder, depression, insomnia, burnout, and resilience in health care workers (HCWs), 12 and 18 months after the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods: Prospective longitudinal study. Results: A total of 207 HCWs (74% female, 46% physicians, 44% nurses) answered; 50% scored over the cut-off for anxiety (GAD-7), 66% for PCL-C, 41% for depression (PHQ-9), 25% for ISI, and 15% started sleep inducers; 52% showed emotional exhaustion (EE), 68% detachment (DE), 39% professional efficacy (EF) at MBI; 27% completed the follow-up questionnaire 6 months later, showing a significant reduction in nearly all scores (GAD-7 median 11[5-15] vs 7[4-12] (P < 0.001); PCL-C 43[30-58] vs 37[24-50] (P < 0.05); PHQ-9 10[4-16] vs 6[3-12] (P < 0.001); ISI 10[4-15] vs 7[5-12](NS); MBI EE 25[16-35] vs 23 [15-31] (NS), DE 13[8-17] vs 12[8-17], EF 29[25-34] vs 30[25-34]. Living in a flat (OR 2.27 [1.10-4.81], high-intensity-of-care working (2.83 [1.15-7.16] increased risk of anxiety (GAD-7); age between 31-40 y (OR 2.8 [1.11-7.68], being a nurse (OR 3.56 [1.59-8.36] and high-intensity-of-care working (OR 8.43 [2.92-26.8] increased risk of pathological stress (PCL-C). Conclusions: Nearly half of HCWs showed psychological distress, especially nurses, women, and the youngest. A mandatory job change, increasing intensity of care, working in a COVID-19 department, and being infected were negative factors; having a partner and living in a detached house were protective. Six months later, all the psychological domains showed individual improvement.

We evaluated the prognostic performance of systemic inflammatory response syndrome (SIRS), sequential organ failure assessment (SOFA), quick-SOFA (qSOFA), modified early warning score (MEWS), lactates and procalcitonin in septic patients. Prospective study on adults with sepsis in the Emergency Department (ED). Area under the Receiver operator characteristic curve (AUC) was calculated to assess how scores predict mortality at 30 and 60 days (d) and upon admission to Intensive care unit (ICU). Among 469 patients, mortality was associated with higher SOFA, qSOFA, MEWS and lactates level. ICU admission was associated with higher SOFA, procalcitonin and MEWS. Prognostic performance for mortality were: SOFA AUC 30 d 0.76 (0.69-0.81); 60 d 0.74 (0.68-0.79); qSOFA AUC 30 d 0.72 (0.66-0.79); 60 d 0.73 (0.67-0.78) and lactates AUC 30 d 0.71 (0.60-0.82); 60d 0.65 (0.54- 0.73). For the outcome ICU admission, procalcitonin had the highest AUC [0.66 (0.56-0.64], followed by SOFA [0.61 (0.54-0.69)] and MEWS [0.60 (0.53-0.67)]. SOFA, qSOFA and lactates assessment after arrival in the ED have a good performance in detecting patients at risk of mortality for sepsis. Procalcitonin is useful to select patients that will need ICU admission.

Background A quick and accurate case identification in the Emergency Department (ED) during the SARS-CoV-2 pandemic is crucial for clinical management and to prevent spread of infections. The gold standard for diagnosing SARS-CoV-2 infection is the real-time reverse transcription polymerase chain reaction (RT-PCR) test in upper airways swabs. However, the procedure is available in few specialized laboratories and requires an average sample processing time of about 6 hours from its inception. The development of reliable but cheaper and faster point-of-care tests was expected to be useful either for population-screening or as first aid tests in the ED. Rapid antigenic diagnostic tests (Ag-RDTs), directly detect SARS-CoV-2 proteins produced by the replicating virus in respiratory specimens, were proved to be candidates in both cases. However, data on their effectiveness are still few and controversial. The aim of the study is to establish the accuracy of antigen tests to identify SARS-CoV-2 in a high prevalence setting. Methods Results of 324 patients, consecutively admitted to the ED of San Luigi Gonzaga University Hospital in Orbassano (Turin, Italy) between 26 October and 10 November 2020 and subjected to both molecular and antigen tests, were compared. Results Using RT-PCR as gold standard, specificity and sensitivity of Ag-RDT were 0.94 (95%CI: 0.90-0.98) and 0.80 (95%CI: 0.75-0.85), respectively. The Ag-RDT positive predictive value was 0.96 (95%CI 0.93- 0.99), and the negative predictive value was 0.72 (95% CI: 0.65-0.79). Patients that tested negative to Ag-RDT but presented with fever and cough or had pneumonia at imaging were more likely to be false negatives. Ag-RDTs best performance occurs in the first days after symptom onset. Conclusions These results confirm the limits of antigenic tests as first line screening tests and suggest that the antigenic test should be integrated with clinical judgement, based on physical and instrumental examinations. Key messages Antigenic tests have a limited effectiveness as first line screening tests. In a high-prevalence setting these tests incorrectly judge as negative many COVID-19 symptomatic patients, making necessary to integrate their results with clinical judgement.

Objectives Patients who arrive at the emergency department (ED) with COVID-19, who test negative at the first real-time polymerase chain reaction (RT-PCR), represent a clinical challenge. This study aimed to evaluate if the clinical manifestation at presentation, the laboratory and imaging results, and the prognosis of COVID-19 differ in patients who tested negative at the first RT-PCR compared with those who tested positive and also to evaluate if comorbid conditions patient-related or the period of arrival are associated with negative testing. Study design We retrospectively collected clinical data of patients who accessed the ED from March 1 to May 15, 2020. Methods We compared clinical variables, comorbid conditions, and clinical outcomes in the two groups by univariate analysis and logistic regression. Results Patients who tested negative at the first RT-PCR showed a higher prevalence of cardiopathy, immunosuppression, and diabetes, as well as a higher leukocyte and lower lymphocyte counts compared with patients who tested positive. A bilateral interstitial syndrome and a typical pattern at computed tomography scan were prevalent in the test-negative group. Test-negative patients were more likely to be admitted to the hospital but less likely to need admission in a high level of care ward. The false-negative rate increased from March to May. Conclusion False-negative RT-PCR COVID-19 patients present a similar spectrum of symptoms compared with positive cohort, but more comorbidities. Imaging helps to identify them. True positives had a higher risk of serious complications.

Background and objectives Blood is a critical resource for responding to mass casualty incidents (MCI). The main framework for transfusion preparedness is the American Association of Blood Bank (AABB) Disaster Operation Handbook. A disaster preparedness plan for co-ordinated blood supply was issued in Italy in 2016. Aim To assess the level of preparedness of the Transfusion Centers (TS) in the Piedmont region, to evaluate the applicability of AABB checklist and to evaluate the application of the Italian plan. Materials and methods We surveyed all the Regional Transfusion Centers (TS) using the AABB checklist, addressing 74 priority action items grouped according to 16 preparedness domains. The Italian 2016 plan has been considered the regulatory cut-off and hospitals were stratified based on the type and the TS workload. A principal component analysis (PCA) was conducted to summarize the variance among centres. Results Twenty-one out of 25 TS agreed to participate. Eighty-one % were at high and 18% were at medium level of preparedness. All but two centres were above the cut-off determined by the Italian law. A significant better preparedness was found in medium size hospitals compared to bigger and smaller hospitals. Other than that, the different TS showed a quite homogeneous distribution of preparedness variance. Conclusions This study demonstrated a good level of preparedness in the Piemonte TS, above the Italian law requirements in the majority of TS. The AABB checklist could be used to highlight gaps and needs in the regional TS networks in case of emergency crisis.

Resource allocation in our overcrowded hospitals would require classification of inpatients according to the severity of illness, the evolving risk and the clinical complexity. Reverse triage (RT) is a method used in disasters to identify inpatients according to their use of hospital resources. The aim of this observational prospective study is to evaluate the use of RT in medical inpatients of an Italian Hospital and to compare the RT score with National Early Warning Score, Sequential Organ Failure Assessment and Charlson Comorbidity Index. Cluster sampling was performed on high dependency unit (HDU), geriatrics (Ger) and internal medicine (IM) wards. We calculate RT, NEWS, SOFA and CCI from inpatient charts. Length of stay (LOS), transfer to a higher level of care, death and discharge date were collected after 30 days. We obtained demographics, comorbidities, severity and clinical complexity of 260 inpatients. We highlighted differences in NEWS, SOFA and CCI in the three divisions. On the contrary RT score was uniformly high (median 7), with 85% of patients with RT = 8. NEWS, SOFA and CCI were higher in patients with higher RT score. We used the sum of the interventions listed by RT (RT sum) as a proxy of the level of care needed. RT-sum showed moderate correlation with NEWS (r = 0.52 Spearman, p

to investigate the characteristics of patients affecting the duration of positivity test by RT-PCR in the population of Piedmont, a Region of North-West of Italy. DESIGN: observational cohort study.from the administrative database of the regional SARS-CoV-2 surveillance system, a cohort of all patients who tested positive by a RT-PCR assay to SARS-CoV-2 occurring from 22.02.2020 to 30.09.2020 in the Piedmont Region (N. 29,292) was obtained. The cohort has been linked to the hospital discharge database and to the vital statistics database.outcome of the study was the risk of non negativization, estimated by fitting Generalizing Estimating Equation model (GEE), a longitudinal model which consider for each subject several records collected on fixed time intervals 15, 30, 45 or 60+ days from the first positive test. Negativization was defined as the condition in which two consecutive samples taken from the patient at least 24 hours apart were negative for the presence of SARS-CoV-2.the median duration of positive RT-PCR was 27 days. A higher median of days until positive persistence was observed in people over 80 (34 days, IQR 25-49), female (28 days, IQR 18-40), symptomatic patients (28 days, IQR 19-40), hospitalized people (32 days, IQR 21-44), patients with Charlson's index0 (34 days, IQR 23-49), patients host of elderly nursing homes (37 days, IQR 25-51). In the GEE multivariable model, the variables associated to the non negativization at all times intervals were: older age (at 15th day: class 65+, OR 2.56, 95%CI 2.39-2.74), female gender (at 15th day: OR 1.12, 95%CI 1.06-1.18), and to be hospitalized for COVID-19 (at 15th day: OR 1.38, 95%CI 1.29-1.48). The presence of comorbidities and of symptoms were associate with the non negativization at 15th day (respectively, class 4+: OR 1.29, 95%CI 1.08-1.56 and symptoms: OR 1.20, 95%CI 1.13-1.27), but not at 45th day.older age, female gender, presence of comorbidities and severity of disease (proxy hospitalization for COVID-19) were risk factors for non negativization at all times intervals. The presence of symptoms was a risk factors for the non negativization after 2 weeks from the first diagnosis and not at 45th day. Using a longitudinal model for the analysis of the dataset, it is possible to compare the weight of the variables included in the model at different times and correct an overestimation of the attributable risk after the first considered time interval.

PURPOSE: COVID-19 cancer patients (C19-CP) represent a population at high risk for mortality, whose clinical characteristics are still unknown in the second SARS-CoV-2 wave. The aim of this retrospective study was to compare epidemiology and clinical presentation of C19-CP referring to the emergency department (ED) of our institution (San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy), in a 3-week observation period of the first and second COVID-19 waves, starting from the introduction of the corresponding national lockdowns. METHODS: We retrieved ED admissions from March 9 to 29, 2020, for the first wave, and from October 24 to November 13, 2020, for the second wave. We collected clinical characteristics of consecutive patients with molecularly confirmed SARS-CoV-2 infection. We also considered untested or SARS-CoV-2–negative cancer patients referring to the ED in the reference time frames. RESULTS: C19-CP in the second wave exceeded those in the first wave despite the nonsignificant difference (39 of 576 v 8 of 163; P = .5). Compared with nononcological patients, C19-CP were older (median age 70 years [interquartile range 61-77] v 60 years [interquartile range 45-73]; P = .02) and presented more often with ≥ 2 comorbidities (40.4% v 24.3%; P = .02). Compared with nononcological patients, in C19-CP, respiratory failure (29 of 47 v 321 of 692; P = .049) and hospitalization (37 of 47 v 363 of 692; P = .0004) were higher, with comparable frequencies across the waves. Five of 24 and 10 of 27 hospitalized cancer patients in the first and second waves developed SARS-CoV-2 infection during hospitalization. CONCLUSION: C19-CP were a vulnerable population, irrespective of the COVID-19 waves. This highlights the need to prioritize vaccinations in oncological patients to safeguard and guarantee optimal anticancer care.

Objective There are many different methods for computing the Predisposition Infection Response Organ (PIRO) dysfunction score. We compared three PIRO methods (PIRO1 (Howell), PIRO2 (Rubulotta) and PIRO3 (Rathour)) for the stratification of mortality and high level of care admission in septic patients arriving at the Emergency Department (ED) of an Italian Hospital. Design, setting and participants We prospectively collected clinical data of 470 patients admitted due to infection in the ED to compute PIRO according to three different methods. We tested PIRO variables for the prediction of mortality in the univariate analysis. Calculation and comparison were made of the area under the receiver operating curve (AUC) for the three PIRO methods, SOFA and qSOFA. Results Most of the variables included in PIRO were related to mortality in the univariate analysis. Increased PIRO scores were related to higher mortality. In relation to mortality, PIRO 1 performed better than PIRO2 at 30 d ((AUC 0.77 (0.716–0.824) vs. AUC 0.699 (0.64–0.758) (p = 0.03) and similarly at 60 d (AUC 0.767 (0.715–0.819) vs AUC 0.709 (0.656–0.763)(p = 0.55)); PIRO1 performed similarly to PIRO3 (AUC 0.765 (0.71–0.82) at 30 d, AUC 0.754 (0.701–0.806) at 60 d, p = ns). Both PIRO1 and PIRO3 were as good as SOFA referred to mortality (AUC 0.758 (0.699, 0.816) at 30 d vs. AUC 0.738 (0.681, 0.795) at 60 d; p = ns). For high level of care admission, PIRO proved inferior to SOFA. Conclusions We support the use of PIRO1, which combines ease of use and the best performance referred to mortality over the short term. PIRO2 proved to be less accurate and more complex to use, suffering from missing microbiological data in the ED setting.

Objective:To assess the psychological impact of a mass casualty incident (MCI) in a subset of personnel in a level I hospital.Methods:Emergency department staff responded to an MCI in June 2017 in Turin, Italy by an unexpected sudden surge of casualties following a stampede (mass escape). Participants completed the Psychological Simple Triage and Rapid Treatment Responder Self-Triage System (PsySTART-R), which classified the potential risk of psychological distress in “no risk” versus “at risk” categorization and identified a range of impacts aggregated for the population of medical responders. Participants were administered a questionnaire on the perceived effectiveness of management of the MCI. Two months later, the participants were evaluated using the Hospital Anxiety and Depression Scale (HADS), the Kessler Psychological Distress Scale (K6), and the Posttraumatic Stress Disorder Checklist (PCL-5).Results:The majority of the responders were classified as “no risk” by the PsySTART-R; no significant differences on HADS, K6, and PCL-5 were found in the participants grouped by the PsySTART-R categories. The personnel acquainted to work in emergency contexts (emergency department and intensive care unit) scored significantly lower in the HADS than the personnel usually working in other wards. The number of positive PsySTART-R criteria correlated with the HADS depression score.Conclusions:Most of the adverse psychological implications of the MCI were well handled and averted by the responders. A possible explanation could be related to factors such as the clinical condition of the victims (most were not severely injured, no fatalities), the small number of casualties (87) brought to the hospital, the event not being considered life-threatening, and its brief duration, among others. Responders had mainly to cope with a sudden surge in casualties and with organizational issues.

Background Reverse triage (RT) identifies patients eligible for discharge and have been proposed to cope with daily surge. Nevertheless, early discharge could increase the rate of readmission. Our aim is to test the effectiveness and safety of RT alone and with readmission screening tools (Identification Senior At Risk [ISAR], HOSPITAL, and Groeningen Frailty Index [GFI] scores) to predict appropriate discharge. Material and methods We prospectively assessed every 4 days (t0 ) inpatients of medical divisions (High Dependency Unit (HDU), Internal Medicine (IM), and Geriatrics (Ger)) of an Italian Hospital. RT score was calculated for each patient and an RT ≤3 identified those eligible for safe discharge. ISAR, HOSPITAL, and GFI were then applied. We assessed reinstituting of interventions and transferring to an increased level of care unit at 4 days as an ethical proxy of consequential medical events following hypothetical discharge. Date of effective discharge, death, and readmission were measured at 4, 7, 15, and 30 days after the first evaluation. Results Twenty-five (9.6%) out of 260 patients in our sample had an RT ≤3. Twenty-four (96%) of them compared with 205 (87%) of the RT >3 group (P = NS) were discharged. Patients with RT ≤3 were discharged significantly earlier (3.5 vs 8 days after t0 [P = 0.0002]). In the RT ≤3 group, all but one patient were alive and healthy at 7, 15, and 30 days. The HOSPITAL score seemed to have the best concordance with RT (84%), in comparison with the ISAR (52%) and the GFI (48%) scores. RT showed a low sensitivity (22%) and high specificity (95%), which was even higher when using RT associated with readmission screening tools. Conclusions Reverse triage proved to be a safe and conservative tool, with high specificity alone and with readmission screening tools. RT correctly identifies patients that will be discharged earlier.

The evaluation of pleuritic pain in the emergency department (ED) presents a considerable challenge for the attending physician. Chest radiography (CXR) is a basic test, but its sensitivity is low, and often more sophisticated imaging techniques are needed. Our aim is to assess the diagnostic value of bedside B-mode lung ultrasound (LUS) in the visualization of radio-occult pulmonary lesions. Forty-nine patients complaining of pleuritic pain with negative CXR were prospectively studied by LUS. Detection of at least one of the following sonographic signs in the painful thoracic area was considered diagnostic: (i) the absence of pleural sliding; (ii) the focal alveolar-interstitial syndrome (AIS), defined by multiple artifacts B-line; (iii) the peripheral alveolar consolidation (PAC), defined by hypoechoic subpleural images; and (iv) the pleural disruption with thickening and irregularity of the line, with or without localized effusion. The final diagnoses were confirmed by spiral CT scanning (n = 12) and follow-up (n = 37). Final diagnoses were chest wall pain (n = 30), pleuropneumonia (n = 14), pulmonary embolism (n = 4), lung metastasis (n = 1). In 18 patients of the group with pulmonary conditions, LUS showed signs of pleurisy. They were PAC (n = 12), AIS (n = 17), pleural disruption (n = 17). If any sign is considered, the sensitivity of LUS in the diagnosis of radio-occult lesions was 94.7%, specificity was 96.7%, positive and negative predictive values were 94.7% and 96.7%, respectively, and accuracy was 95.9%. In patients with pleuritic pain of unknown cause, real-time LUS enables the diagnosis of radio-occult lung and pleural lesions.

Purposes: Multiple artifacts B lines (B+) at transthoracic lung ultrasound have been proposed as a sonographic sign of pulmonary congestion. Our aim is to assess B+ clearance after medical treatment in acute decompensated heart failure (ADHF) and to compare the usefulness of sonography with other traditional tools in monitoring resolution of pulmonary congestion. Methods: Eighty-one patients with a diagnosis of ADHF were submitted to lung ultrasound and chest radiography at admission, and 70 of them underwent the same procedures as control group after 4.2 ± 1.7 days of medical treatment. The ultrasound examination was performed with 11 scans on as many anterolateral thoracic areas (6 on the right side and 5 on the left side). Then, we calculated a sonographic score counting the B+ scans and compared it with radiologic score for extravascular lung water, clinical, and plasma brain natriuretic peptide improvement. Main Results: All patients showed B+ pattern at admission and significant clearing after treatment, with median number of 8 positive scans (range, 3-9 scans) vs 0 (range, 0-7 scans) (P b.05). Our sonographic score showed positive linear correlation with radiologic score (r = 0.62; P b .05), clinical score (r = 0.87; P b .01), and brain natriuretic peptide levels (r = 0.44; P b .05). Δ Sonographic score correlated with Δ clinical (r = 0.55; P b .05) and radiologic (r = 0.28; P b .05) scores. Conclusions: B line pattern mostly clears after adequate medical treatment of ADHF and represents an easy-to-use alternative bedside diagnostic tool for clinically monitoring pulmonary congestion in patients with ADHF.

Thrombotic thrombocytopenic purpura (TTP) is a generalized disorder of the microcirculation characterized by microangiopathic hemolytic anemia (MHA), thrombocytopenic purpura and systemic microvascular thrombi. TTP has been previously described in two patients with prostate cancer (PC). We report a third case of TTP in a 61-year-old man with hormone-refractory bone metastatic PC. The syndrome presented with confusion, anuric acute renal failure, thrombocytopenia and MHA. A satisfactory recovery was achieved after plasma exchange (PE). TTP should be included in the coagulation disorders occurring in PC patients. Early treatment with plasma exchange is recommended in these particular cases.

Diffuse comet-tail B-line artifacts in lung ultrasound are a sign of alveolar-interstitial syndrome, but isolated transthoracic scans positive for B-lines (multiple B lines or B+) could be detected in other conditions. The aim was to assess the prevalence and distribution of this sonographic sign in patients with normal lung or isolated alveolar consolidation in chest radiography.Two hundred seventeen patients consecutively admitted to this emergency medicine unit with any diagnosis and without radiographic or clinical evidence of diffuse interstitial syndrome were analyzed. Each patient underwent chest radiography and lung sonographic examination with four anterolateral chest scans per side.Of the 1736 sonographic scans performed, 13.2% were positive for the B+ pattern. Positive scans significantly corresponded to laterobasal areas or radiographic opacities due to lung alveolar consolidations (p0.005). Twenty percent of the laterobasal scans of 145 patients with radiologically normal lung were positive. The negative predictive value of B+ was 83.9% (95% confidence interval: 78.2-89.7%), with a specificity of 90.3% (95%CI: 85.5-95.1%) for predicting any localized radiographic pulmonary opacity.B+ scans can be detected in the chest areas surrounding an isolated alveolar consolidation and in the laterobasal scans of a radiographic normal lung. These features should always be considered when lung ultrasound is performed to rule out the alveolar-interstitial syndrome in an emergency setting. Moreover, B+ patterns have a satisfactory negative predictive value for radiographic lung opacities, which could have added diagnostic value in the ED evaluation of dyspneic patients.

Thrombotic thrombocytopenic purpura (TTP) is a generalized disorder of the microcirculation characterized by microangiopathic hemolytic anemia (MHA), thrombocytopenic purpura and systemic microvascular thrombi. TTP has been previously described in two patients with prostate cancer (PC). We report a third case of TTP in a 61-year-old man with hormone-refractory bone metastatic PC. The syndrome presented with confusion, anuric acute renal failure, thrombocytopenia and MHA. A satisfactory recovery was achieved after plasma exchange (PE). TTP should be included in the coagulation disorders occurring in PC patients. Early treatment with plasma exchange is recommended in these particular cases.

BACKGROUND: Natural killer (NK) cells are a key component of innate immunity; their activity is modulated by cytokines and hormones and is influenced by diet. In obesity, a higher risk of cancer and infections has been demonstrated. Studies on NK cell activity have yielded inconsistent results; NK cell sensitivity to modulators has not been assessed before. OBJECTIVE: In this case–control study, we assessed both spontaneous NK cell activity and responsiveness to positive (interleukin (IL)-2) and negative (cortisol) modulators in uncomplicated obesity; we searched for correlations between NK cell activity and anthropometric, dietary and metabolic variables. METHODS: In all, 21 obese (six males/15 females) and 21 age- and sex-matched healthy nonobese subjects underwent clinical examination and dietary and laboratory analyses. Spontaneous and modulated NK activities of peripheral blood mononuclear cells were measured by enzyme-release cytotoxicity assay. RESULTS: Spontaneous NK cell activity was not different in obese subjects vs controls. IL-2 stimulated and cortisol inhibited NK cell activity in both populations. Cortisol-dependent inhibition was lower in the obese than in the control group (−24.4±2.9 vs −38.6±3.3%, P=0.002), but decreased sensitivity was restricted to women (P=0.0007). In obese subjects, cortisol-dependent inhibition negatively correlated with serum leptin levels (r=−0.54, P=0.02) and, in women, with body mass index (r=−0.63, P=0.01); IL-2-dependent stimulation positively correlated with dietary carbohydrates (r=0.61, P=0.005) and serum LDL levels (r=0.55, P=0.009) and negatively correlated with dietary lipids (r=−0.71, P=0.0006). CONCLUSION: Spontaneous and IL-2-inducible NK cell activity is normal in uncomplicated obesity. Sensitivity to IL-2 correlates with fat and carbohydrate intake. Sensitivity to glucocorticoids negatively correlates with serum leptin levels and is significantly diminished in obese women, in whom it correlates with body mass index.