Assessing the effects of habitat patches ensuring propagule supply and different costs inclusion in marine spatial planning through multivariate analyses.

Marine Protected Areas are considered key tools for conservation of coastal ecosystems. However, many reserves are characterized by several problems mainly related to inadequate zonings that often do not protect high biodiversity and propagule supply areas precluding, at the same time, economic important zones for local interests. The Gulf of Naples is here employed as a study area to assess the effects of inclusion of different conservation features and costs in reserve design process. In particular eight scenarios are developed using graph theory to identify propagule source patches and fishing and exploitation activities as costs-in-use for local population. Scenarios elaborated by MARXAN, software commonly used for marine conservation planning, are compared using multivariate analyses (MDS, PERMANOVA and PERMDISP) in order to assess input data having greatest effects on protected areas selection. MARXAN is heuristic software able to give a number of different correct results, all of them near to the best solution. Its outputs show that the most important areas to be protected, in order to ensure long-term habitat life and adequate propagule supply, are mainly located around the Gulf islands. In addition through statistical analyses it allowed us to prove that different choices on conservation features lead to statistically different scenarios. The presence of propagule supply patches forces MARXAN to select almost the same areas to protect decreasingly different MARXAN results and, thus, choices for reserves area selection. The multivariate analyses applied here to marine spatial planning proved to be very helpful allowing to identify i) how different scenario input data affect MARXAN and ii) what features have to be taken into account in study areas characterized by peculiar biological and economic interests.

Violence against women in Rome: An analysis of cases treated in the gynecology emergency department of the hospital Umberto I between 1999 and 2013.

BACKGROUND: The gynecological emergency department of the Policlinico Umberto I, Rome sees an average of about 30 cases of violence against females each year. It is stressed that these cases are not representative of all cases of violence against women in Rome and they cannot be used to estimate the prevalence or incidence of the phenomenon, but they may provide some insight on the victims and their aggressors, the use of drugs or alcohol, factors which may affect the decision to report the attack to the police and attacks on children. METHODS: The case records of all 458 females seen in the emergency department between 1999 and 2013 were retrieved, data were extracted and an Excel worksheet was prepared. Temporal variation in the numbers of cases, the types of aggression, the use of drugs or alcohol, reporting the attack to the police and violence against children were specifically investigated using frequency tabulations and appropriate statistical tests. RESULTS: There has been little change in the number of cases seen during the 15 year period; there is no significant seasonal effect or difference between the days of the week. Just over half of the attacks were reported to the police, but this was less likely among the older victims. About 87% of the cases involved vaginal and/or anal penetration. The use of drugs and/or alcohol was most common, 43%, among unmarried women aged 21-25. There were 32 cases of violence against children aged under 16. CONCLUSIONS: There has been little change in the number and characteristics of violent attacks on women seen at this large hospital in Rome over the years 1999-2013.These cases provide little information about the general epidemiology of violence against women, although they do imply that this great social and cultural problem continues unabated in Rome.

Laser vaporization in the management of CIN.

AIMS: To evaluate the effectiveness of laser CO2 vaporization in high-grade cervical intraepithelial neoplasias and to assess the diagnostic reliability of cytology, colposcopy, microbiology and HPV tests in predicting recurrence in a long-term outcome. METHODS: Forty-four patients affectd by high-grade cervical intraepithelial neoplasia (HG-CIN) were submitted to laser CO2 vaporization and followed-up a minimum of five years. Vaginal smears for microbiological examination were detected. HPV testing was performed by polymerase chain reaction (PCR). RESULTS: The average age of the patients was 19.5 years (range 15-24). The cure rate after a single treatment was 95%. Two cases (5%) revealed HG-CIN persistence after three months. The five year follow-up of all cases submitted to a second laser procedure revealed negative cytologic and colposcopic findings. CONCLUSIONS: A higher degree of expertise and experience from the colposcopist and long-term follow-up proves the effectiveness of laser vaporization in the management of CIN in young women. It has been suggested that HPV infection alone may not be sufficient to promote carcinogenesis and that other cofactors could be involved. Microbiological tests are important to identify and treat any inflammation which might represent a cofactor of HPV infection in the pathogenesis of cervical dysplasia. Cytocolposcopic long-term follow-up, microbiological and HPV tests can improve regression of disease.

Prediction of persistent vaginal intraepithelial neoplasia in previously hysterectomized women by high-risk HPV DNA detection.

AIM: To estimate the incidence and latency of Vaginal Intraepithelial Neoplasia (VAIN) in women previously hysterectomized for benign/malign pathology and to evaluate the role of high risk HPVs in the prediction of persistent or recurrent disease. SUBJECTS AND METHODS: 830 women with prior hysterectomy for benign/malign pathologies followed by cytological scraping and vaginal colposcopy. Forty-four patients presented VAIN lesions confirmed by histopathological diagnosis. HPV DNA test was performed at the time of diagnosis. Patients were treated by Laser CO(2) vaporization and underwent follow-up by cytology, colposcopy for a mean period of 3 years. HPV DNA test was performed at 6 months after treatment and every years. Persistent or relapsed disease was confirmed by histopathology. RESULTS: Incidence of VAIN in women hysterectomized for benign pathologies did not differ significantly from the malign group. VAIN degree was more severe in the hysterectomized patients with cervical malignancy and subsequently radiated respect to non-radiated patients. The HPV DNA test at 6 months after VAIN treatment showed fifteen positive cases: twelve HPV 16 (80%) and three HPV 18 (20%). In five cases HPV DNA test was positive with a persistent negative cytological smear during the years. Positivity to high-risk HPV (either 16 or 18) was significantly higher in the patients with relapse to VAIN (10/44, p<0.002). CONCLUSIONS: We suggest to include HPV DNA test in addition to cytology in the follow-up of patients previously treated for VAIN, in order to predict VAIN persistence or progression in vaginal carcinoma before cytology becomes abnormal.

Correlation between squamous intraepithelial lesions (SILs) and bacterial vaginosis.

Bacterial vaginosis (BV) is a condition that seldom occurs in prepuberal girls or postmenopausal women, suggesting a hormonal component in its aetiology. The precise mechanisms by which BV arises are not fully understood. One proposed mechanism suggests that carcinogenic nitrosamines act either independently or via human papilloma virus (HPV). Human papillomavirus is known to be associated with the development of squamous intraepithelial lesion (SIL). Still today the relationship between BV and SIL is debated. Many confounding factors regarding the relationship between BV and SIL include the presence of HPV and/or other sexually transmitted diseases. In a case-controlled study the correlation between BV, SIL and the presence of HPV was evaluated. BV was diagnosed according to standard criteria: vaginal pH > 4.5; positive amine test or 'whiff' test; presence of clue cells and abnormal discharge. High risk-HPV testing by PCR was performed. X2 Pearson analysis was applied for statistical evaluation of data. The results of the study have shown that BV is not associated with SIL.

Cervical intraepithelial neoplasia: risk factors for persistence and recurrence in adolescents.

One of the most common sexually transmitted infections in adolescents is human papillomavirus. These infections can occur in one or multiple areas of the female genitalia but the vulva is usually the initial site of implantation for HPV. We carried out a long-term follow-up study of adolescents to evaluate the incidence of single or multiple lesions in the lower genital tract, the correlation between sexual behaviour and their localisation and behavioural risk factors for persistence and recurrence of HPV lesions and cervical intraepithelial lesion (CIN). We interviewed 268 women aged 12-21 years who had previously had cytology and/or physical examination suspicious for HPV infection. We asked them information about their lifestyle, sexual behaviour, work, personal or family history of genital warts and school attendance. Those who smoked more than five cigarettes a day were considered "smokers". We have no specific data about oral contraception although we know that none of the patients had used oral contraceptives for more than two years. Two hundred and thirty-four young women between the ages of 12 and 21 years were included in the study. The diagnostic schedule for a complete evaluation included exo- and endocervical cytology, colposcopy and directed biopsy. We found that in 126 out of 234 (53.8%) adolescents using contraceptives, only 85 (36.3%) had used a condom. The sites most frequently affected by lesions were the vulva, perianus and perineum (194/234; 82.9%), and the cervix (125/234; 53.4%). Vaginal lesions were detected in only 29/234 patients (12.3%). In 161 patients, sexual habits, age at first intercourse (p = 0.68), frequency of intercourse (p = 0.49) and number of lifetime partners (p = 0.27) as well as age (p = 0.26) played a role in transmission and incidence of HPV infection but not in the location of the lesions. This could be due to coexistent clinical and subclinical multiple infections as well as transmission via intercourse or from other sources, including tampons. HPV infection is detected by abnormal pap test, but the low correlation with colposcopic and histological findings in this study justify the support of other examinations such as colposcopy and punch biopsy for diagnosis. Moreover more attention should be paid to the psychological aspect of diagnoses and treatment of adolescents compared to older women as there was a high rate of patients lost in our study: 75/234 (32.05%) before LASER surgery and 55/159 (34.59%) during follow-up. Only 12-45% of sexually active adolescent girls had obtained Pap smear screening. In our study we found no correlation between treatment failure and cigarette smoking or between the use of oral contraceptives and persistence/recurrence after LASER surgery.

Immunohistochemical analysis of epidermal growth factor receptor (EGF-R) and c-erbB-2 and correlation with pathological prognostic variables in endometrial carcinomas.

In this study the immunohistochemical expressions of epidermal growth factor receptor (EGF-R) and erbB-2 in endometrial carcinomas at different stages of disease progression were evaluated and correlated with clinicopathological prognostic variables. Our results indicate that EGF-R and erbB-2 molecules are expressed in normal endometrium as well as in the majority of the carcinomas evaluated (83% and 92% respectively). The intensity of the immunostaining varied greatly (1+ to 3+) in the different tumors. Within these tumors we focused on those characterized by high levels of expression (i.e. overexpression). Expression and overexpression of EGF-R has been associated with poorly differentiated tumors and with a 3.3 times higher risk of a more rapid disease relapse. Overexpression of the erbB-2 oncoprotein was significatively correlated with depth of myometrial invasion (M0-M1 vs M2-M3 p=0.05), pathological stage (stage I vs II-IV p=0.02) and grade of tumor differentiation (G1 vs G2-G3 p=0.001). In particular, c-erbB-2 overexpression was able to discriminate between the different subsets of stage I carcinomas. None of the IA tumors overexpressed the oncoprotein, as compared to IB and IC (41% and 100% respectively, p=0.04). This finding highlights a role for erbB-2 protein as a prognostic parameter in stage I endometrial carcinoma patients.

Human cervical epithelial cells that express HLA-DR associated with viral infection and activated mononuclear cell infiltrate.

The association between the expression of HLA-DR antigens on cervical epithelium and the local immune state of activation in colposcopically obtained biopsy specimens from patients with histologically documented wart virus infection was investigated. In normal cervical epithelium no HLA-DR staining was detected. No or few IL-2R positive cells were found in the contiguous sections. HLA-DR was expressed by epithelial cells in six out of the 14 samples of wart virus infection. The pattern of fluorescence was focal, but strong and diffuse, to the whole epithelial layer. In the six samples with HLA-DR positive epithelium the numbers of IL-2R positive cells in the lamina propria were strongly increased, ranging between 75 and 90%. HLA-DR expression by cervical epithelium was observed in only two of 12 samples from patients with mixed epithelial non-virus related abnormalities. No increase in the numbers of IL-2R positive cells was observed in this group of patients. Additionally, no significant differences in terms of T lymphocyte infiltrate were found among the three groups. The results indicate that wart virus infection is associated with enhanced HLA-DR epithelial expression and they lend support to the concept that in the human cervix the epithelium actively participates in the local immune response.

Infectious agents in tissues from spontaneous abortions in the first trimester of pregnancy.

Some evidence suggests that intrauterine infection plays a major role in the pathogenesis of early pregnancy loss, but the implication and prevalence of microrganisms in the aetiology of spontaneous abortion during the first trimester of pregnancy has not yet been well established. In this study, we analysed the tissues relative to the product of conception from abortions during the first trimester (51 spontaneous abortions and 56 voluntary pregnancy interruptions) in women attending the Gynecological Sciences Perinatology and Puericulture Department of "Policlinico Umberto I". Specimens were investigated by cultural methods for the presence of yeasts, gram positive, gram negative bacteria, and genital mycoplasma. By molecular diagnostic procedures, DNA sequences of Chlamydia trachomatis, herpes simplex viruses, adenovirus, human papillomaviruses and human polyomaviruses BK and JC were searched. None of these agents could be found in voluntary pregnancy interruption samples, with the exception of 3.6% of specimens positive for adenovirus, whereas spontaneous abortion tissues were positive for at least one microrganism by 31.5%. Data analysis showed the occurrence of both monomicrobial and polymicrobial infections.

Detection of viral and bacterial infections in women with normal and abnormal colposcopy.

Signs and symptoms of sexually-transmitted diseases (STD) do not allow any etiological diagnosis in women. Colposcopic findings are seldom pathognomic. Consequently, the microbiology laboratory with the recent availability of molecular diagnostic tools is required to detect the infectious bacterial and/or viral agents involved in STD. In cervical samples of women submitted to gynaecological screening for past or present signs and symptoms of inflammation and with different colposcopic findings, we searched by molecular approaches Chlamydia trachomatis, Mycoplasma genitalium, herpes simplex virus type 1 and 2, adenovirus and 45 genotypes of papillomaviruses and, by cultural methods Mycoplasma hominis and Ureaplasma urealyticum. Colposcopy permitted us to divide the studied population into three groups: 48 women had negative colposcopic findings, 50 presented signs of flogosis and 100 resulted positive for an abnormal transformation zone (ANTZ) and/or for HPV colposcopic findings. Results obtained by microbiological assays indicated that the prevalence of infectious agents did not always correlate with colposcopy. Double and triple infections were found in groups 2 and 3, with mycoplasmas being the most common microrganisms present in association and quite almost copresent with papillomaviruses.

Abnormal "low grade" transformation zone: current diagnostic gold standard.

The aim of this work was to examine different methods of investigation in the diagnosis of the abnormal "low grade" transformation zone of the portio. Over a period of one year 41 patients subjected to colposcopic examination underwent exo-endocervical sampling for oncologic evaluation and for detection of viral and bacterial infections (HPV, HSV, adenovirus, mycoplasmas and chlamydia trachomatis), as well as portio biopsy. A 65.8% correlation was found between cytology and the HPV-DNA test results, while histology and the presence of the HPV virus agreed in 51.4% of cases. In those cases in which minimal histological alterations were found (koilocytosis) a high percentage of HPV negativity was found. In discordant negative cytologic tests that were however positive for HPV by PCR, the genotypes identified were always 6 and 11.

[Alleged sexual assault. The role of the emergency department gynecologist]. / Riferita violenza sessuale. Il ruolo del ginecologo nel pronto soccorso.

The objective of this paper is to better understand the role of the Emergency department gynecologist in cases of alleged sexual assault. The gynecologist should know that he is a justice collaborator and, as public officer, he has to report to authorities every indictable offense. He should also know that patient's informed consent is required during each step of medical investigation. The doctor should indeed know when, how and where to find and collect evidence of crime and perform, in conformity with the victim's statement, specimens of biologic samples, a pregnancy test and a prophylaxis of sexually transmitted diseases. The gynecologist should evaluate psychological and general state of the patient, take the tailored medical history including the modalities of violent act, perform a physical examination, a genital and rectal examination with accurate description of the lesions and collect evidence of rape. The role of the gynecologist is to document all injuries in order to afterwards establish the conformity with patient's history. He should treat acute physical injuries, offer the counseling for the prevention of sexually transmitted diseases, for the pregnancy prophylaxis and emergency contraception and for psychosocial consequences, report to authorities as required by law and, at last, arrange for follow-up medical care and counseling. Personal experience highlights the necessity of a standard protocol to be used in all Emergency departments. This would allow and facilitate an uniform medical approach to the sexual assault victim as well as an accurate and correct collection of data for legal requirements.

[The role of the gynecologist in first aid in cases of sexual violence. A protocol proposal]. / Il ruolo del ginecologo di Pronto Soccorso nei casi di violenza sessuale. Proposta di protocollo.

The aim of this report is to provide a medical form to use in case of sexual assault, prepared taking into consideration the information lacking at present in most medical reports on the subject. This call for the necessity to conform the medical approach to the same protocol which may also be used from the forensic medicine point of view. More precise information should be obtained about the assault and the injuries inflicted, and also an immediate psychological support should be given to the victim. This information will then serve as a guide to the medical staff.

[Critical review of colpo-histological results in cervix pathology]. / Revisione critica dei risultati colpo-istologici nella patologia cervicale.

BACKGROUND: The objective of this paper was to evaluate the role of squamous metaplasia in the determination of certain colposcopic appearances. METHODS: One thousand four hundred and six infertile outpatients, attending assisted reproduction techniques, underwent a "first level" colposcopy. Two hundred fifty nine abnormal transformation zones were biopsied and the histologic diagnoses were subdivided as follows: squamous metaplasia, squamous metaplasia + koilocytosis, isolated koilocytosis, condyloma, CIN + HPV, cervicitis. RESULTS: Two hundred forty seven cases out of 259 biopsied colposcopic findings (95.4%) were colposcopically classified as grade 1 abnormal transformation zone (thin white epithelium, regular mosaic and punctuation). The correlation between 247 grade 1 abnormal transformation zone colposcopic patterns and histologic diagnosis revealed 105 (42.5%) histologic findings described as squamous metaplasia that resulted immature in 63% of these samples. Between 132 (53.4%) cases that presented a pattern of human papillomavirus infection (condyloma, squamous metaplasia + koilocytosis or isolated koylocitosis), quite two thirds (62%) were described as condylomas, one third (31%) as squamous metaplasia associated with koylocitosis and only 7% as isolated koylocitosis. In conclusion, 42.5% of target biopsies performed on low grade abnormal transformation of the cervix revealed squamous metaplasia, more than half of them revealed one of HPV infection forms, while only 2% represented cervical intraepithelial neoplasia. CONCLUSIONS: Among the low risk female population, one out of two cases of colposcopically low grade pattern should be considered indicative of squamous metaplasia. The results obtained confirm that colposcopic evaluation is unable to distinguish between immature metaplastic transformation of the epithelium and metaplastic epithelium with initial neoplastic transformation.

The emergency department gynaecologist and emergency postcoital contraception.

The emergency department gynaecologist is often faced with requests for emergency postcoital contraception. The physician on duty is usually very busy and does not always have enough time to perform a complete evaluation of the woman's state of health. The emergency gynaecologist who prescribes postcoital contraception also has a number of other problems to cope with in regard to the pharmacological preparations on the market, the efficacy of various methods, the monitoring of side-effects which are not, always, tolerated by all patients and the outcome of his therapeutic prescription. All these aspects should be emphasized in the "first aid" counselling offered to the patients. In conclusion, we consider that any women who decides to use postcoital contraception should have the right to receive assistance of guaranteed quality throughout the period that elapses between taking the drug and the subsequent menstrual cycle. This is not strictly guaranteed by an emergency gynaecological service.

Gynaecological and obstetric audit at a G&O emergency department.

The present study takes into account only the patients that are sent home because their conditions do not require emergency hospitalization in order to try to understand the reasons why a woman seeks emergency treatment at a G&O emergency service.

The influence of obesity in the sexual life of women in menopause. A case control study.

It seemed important to us to investigate sexuality during the post-menopausal and senile period to evaluate whether changes in sexual behaviour are related with endocrine-functional alterations brought on by menopause, or whether social-economic and environmental factors represent the principal cause. Thus 1,500 questionnaires were distributed to women aged from 50 to 87. Of the 1,500 questionnaires distributed, only 713 (47.53%) were returned completely filled-in. All women had been classified for age, civil status and life environment. Our statistic analysis does not seem to have singled out those factors that influence sexual activity in women of advanced age but shows only how age, indifferently from civil status and life environment, represents the most important factor. At the same age other factors, probably attached to psychological features and way of life and thus difficult to define and even less qualifiable, may be of influence, explaining a further percentage of control of those answers not explainable by age.

[Absorption of proteins, carbohydrates and fats in the preterm neonate]. / L'assorbimento delle proteine, dei carboidrati e dei grassi nel neonato pretermine.

Protein, fat and carbohydrate absorption in preterm infants fed on human milk or formulae are reviewed. Even in the most premature infants absorption of protein is satisfactory. Nitrogen net absorption is about 85-90% of intake and results slightly lower with human milk than with formulae. The lower apparent digestibility of human milk is probably due to the poorly degraded IgA immunoglobulins and the rapid transit time. Lactose is well tolerated by the preterm infants despite the low lactase activity at birth. Glucose polymers, which have a low osmotic activity and are suitable for increasing carbohydrate intake of formulae, are well absorbed probably for the activity of salivary amylase and brush border glucoamylase, which have been shown to be well developed at birth. Premature infants absorb fat poorly. This malabsorption that increases with the lowering of gestational age is due to low pancreatic lipase activity and to low intraluminal concentration of bile salts. Due to its bile stimulated lipase activity, non-heat-treated human milk used at least in part is an effective method to improve fat absorption in preterm infants. Faecal energy determined using a calorimetric bomb appears to be a simple and an accurate method to predict faecal fat and avoiding expensive and cumbersome analysis.

Clinical characteristics and response to prophylactic fluconazole of preterm VLBW neonates with baseline and acquired fungal colonisation in NICU: data from a multicentre RCT.

BACKGROUND: Fungal colonisation by Candida spp. affects a high proportion of VLBW neonates in NICU. However, few data are available on the clinical characteristics of colonisation in preterm infants who are colonised at baseline via vertical transmission, compared to preterms who become colonised during their stay in NICU via horizontal transmission. MATERIAL AND METHODS: We reviewed the database of a multicentre, randomised trial of prophylactic fluconazole in VLBW neonates conducted in 8 Italian NICUs in the years 2004 and 2005 (Manzoni et al., NEJM 2007;356(24):2483-95). Per the protocol, all enrolled infants underwent weekly surveillance cultures from birth till discharge. We investigated the frequency of the two different modalities of Candida colonisation in this population, as well as the clinical and outcome characteristics possibly related to them. RESULTS: Overall, Candida colonisation affected 54 of 336 infants (16.1%). Baseline (i.e., detected <3(rd) day of life) colonisation affected 16 (4.7%), and acquired 38 (11.4%), of the 54 colonised preterms. Infants with baseline colonisation had significantly higher birth weight (1229 ± 28 g vs. 1047 g ± 29, p = 0.01) and gestational age (30.2 wks ± 2.7 vs. 28.5 wks ± 2.6, p = 0.01), and were significantly more likely to limit progression from colonisation to invasive Candida infection when fluconazole prophylaxis was instituted (21.6% vs. 42.7%, p = 0.009). Isolation of C. parapsilosis was significantly more frequent in infants with acquired colonisation. CONCLUSIONS: Infants with baseline and acquired colonisation differ for demographics characteristics and for their response to fluconazole prophylaxis. This information may be useful for targeting more accurate management strategies for these two different groups of colonised preterms in NICU.