Tailored support may reduce mental and relational impact of infertility on infertile patients and partners.

RESEARCH QUESTION: What is the psychological impact of infertility on infertile patients and partners of infertile patients? DESIGN: This online, international, quantitative survey assessed the impact of infertility on mental health, relationships and daily activities for 1944 respondents. Respondents were male or female infertile patients (n = 1037) or partners to infertile patients (n = 907; not necessarily partners of the patient sample) and were recruited at different stages of the treatment journey. RESULTS: The most common emotions were 'sadness' at infertility diagnosis and 'anxiety' during treatment. Emotions differed in nature and intensity throughout the journey. Envy of others who achieved pregnancy was frequently reported by women. More than half of respondents (60.4%; n = 1174) perceived the infertility journey to have impacted their mental health, and 44.1% (n = 857) of respondents sought mental health support. More patients reported mental health impacts (70.1%, n = 727) than partners (49.3%, n = 447). One in three respondents indicated that their relationship had suffered due to the infertility diagnosis. Of these respondents, 55.0% (n = 409) strongly agreed that infertility caused an emotional strain. Patients more often than partners reported a detrimental impact on daily activities. Respondents most commonly agreed with statements regarding an 'effect on work-life balance'. CONCLUSION: Treatment journey stages are defined by their impact profile, which differs between infertile patients and partners of infertile patients. Negative impacts are diverse (mental health, relational, daily activities). There was disparity between the number of respondents reporting mental health issues and the number seeking mental health support. This indicates the need for support services tailored to different treatment stages.

Anxiety and depression symptoms after virological clearance of COVID-19: A cross-sectional study in Milan, Italy.

Prevalence of anxiety or depression was investigated in 105 coronavirus disease 2019 (COVID-19) patients at 1 to 3 months from virological clearance by hospital anxiety and depression scale (HADS-A/D). 30% of patients displayed pathological HADS-A/D, 52.4% showed persistent symptoms. Pathological patients with HADS-A/D more commonly reported symptom persistence, even after adjustment for age, gender, and disease severity. Psychological assessments should be encouraged in COVID-19 patients' follow-up.

Barriers and factors associated with significant delays to initial consultation and treatment for infertile patients and partners of infertile patients.

RESEARCH QUESTION: What are the key drivers and barriers for infertile patients and their partners to see an infertility specialist and initiate treatment? DESIGN: An online, international, 30-minute quantitative survey collected data from 1944 respondents from nine countries. Respondents were infertile patients (n = 1037) or partners of infertile patients (n = 907; but not necessarily partners of the patient sample), at different stages of the treatment journey. RESULTS: The overall average times were 3.2 years to receiving a medical infertility diagnosis, 2.0 years attempting to achieve pregnancy without assistance before treatment, and 1.6 years of treatment before successful respondents achieved pregnancy. The most common driver for considering treatment after a consultation (n = 1025) was an equal desire within the couple to have a child (40.8%). Of the partners (n = 356), 29.8% reported that transparency of information from healthcare professionals about treatment expectations was important. A significantly higher proportion of respondents seeking treatment reported that healthcare professionals offered supportive services (61.2%) and mental health services (62.0%), than of the 207 respondents who did not seek treatment (32.4% and 36.7%, respectively; P < 0.001). Perceived cost was the most commonly reported barrier for respondents not seeking a consultation (37.5% of n = 352) or treatment (42.0% of n = 207). Of the 95 respondents who discontinued treatment, 34.7% discontinued due to the financial impact. CONCLUSIONS: Respondents reported significant delays to seeking treatment, probably negatively impacting the chances of achieving pregnancy. Motivational coherence within couples was a key driver and cost of treatment was the main barrier. Reported supportive service offerings by healthcare professionals were significantly associated with continuation of the treatment journey.

Pandemic nightmares: Effects on dream activity of the COVID-19 lockdown in Italy.

COVID-19 has critically impacted the world. Recent works have found substantial changes in sleep and mental health during the COVID-19 pandemic. Dreams could give us crucial information about people's well-being, so here we have directly investigated the consequences of lockdown on the oneiric activity in a large Italian sample: 5,988 adults completed a web-survey during lockdown. We investigated sociodemographic and COVID-19-related information, sleep quality (by the Medical Outcomes Study-Sleep Scale), mental health (by the Depression, Anxiety, and Stress Scales), dream and nightmare frequency, and related emotional aspects (by the Mannheim Dream Questionnaire). Comparisons between our sample and a population-based sample revealed that Italians are having more frequent nightmares and dreams during the pandemic. A multiple logistic regression model showed the predictors of high dream recall (young age, female gender, not having children, sleep duration) and high nightmare frequency (young age, female gender, modification of napping, sleep duration, intrasleep wakefulness, sleep problem index, anxiety, depression). Moreover, we found higher emotional features of dream activity in workers who have stopped working, in people who have relatives/friends infected by or who have died from COVID-19 and in subjects who have changed their sleep habits. Our findings point to the fact that the predictors of high dream recall and nightmares are consistent with the continuity between sleep mentation and daily experiences. According to the arousal-retrieval model, we found that poor sleep predicts a high nightmare frequency. We suggest monitoring dream changes during the epidemic, and also considering the implications for clinical treatment and prevention of mental and sleep disorders.

Phone follow up to families of COVID-19 patients who died at the hospital: families' grief reactions and clinical psychologists' roles.

A proportion of persons affected by coronavirus disease-19 (COVID-19) die and do so in extraordinary circumstances. This can make grief management extremely challenging for families. The Clinical Psychology unit of an Italian hospital offered a bereavement follow-up call to such families. This study aimed to explore the families' experiences and needs collected during these calls, and the role that the psychologists played through the call. A total of 246 families were called over 3 months. Multiple qualitative methods included: (i) written reports of the calls with relatives of patients who died at the hospital for COVID-19; (ii) qualitative semi-structured interviews with psychologists involved in the calls; (iii) observation of psychologists' peer group discussions. A thematic analysis was conducted. Six themes emerged: without death rituals, solitary, unexpected, unfair, unsafe, coexisting with other stressors. Families' reactions were perceived by psychologists as close to a traumatic grief. Families' needs ranged from finding alternative rituals to giving meaning and expressing different emotions. The psychologists played both a social-institutional and a psychological-human role through the calls (e.g., they cured disrupted communication or validated feelings and choices). This study highlighted the potential of traumatic grief of families of COVID-19 victims, and provided indications for supporting them within the space of a short phone call.

Psychological and psychosocial implications for parenting a child with phenylketonuria: a systematic review.

INTRODUCTION: Since phenylketonuria (PKU) appears to have specificities that might challenge the parents' adaptation and well-being, the present review aimed to evaluate the impact of parenting a child with PKU on parents' psychological and psychosocial functioning. EVIDENCE ACQUISITION: A systematic electronic search was conducted using PubMED, Scopus, Embase, PsychInfo, Google Scholar and Cochrane Database to identify studies exploring psychological and psychosocial issues of parents of PKU children. The search retrieved 427 articles to review against inclusion criteria; a total of 17 studies were included in the review. Results were summarized qualitatively. EVIDENCE SYNTHESIS: Findings revealed a complex pattern of interrelated factors both on parental psychological wellbeing and psychosocial functioning. In particular, crucial for parents' adjustment to child PKU are the diagnosis resolution and the perceived social support; parents showed good coping strategies and quality of life; while, with regard to mental health, the studies reviewed showed inconsistent results, thus pointed out a moderate level of distress. The review examines patterns of results across studies and discusses methodological heterogeneities and problems related to different or inconsistent findings. CONCLUSIONS: Parenting a child with PKU had direct implications on the diagnosis resolution, the parents mental health and the disease management. Findings could help healthcare professionals to identify situations at risk for psychological maladjustments both in parents and in children, as the unresolved diagnosis or a tendency toward the social isolation. Results highlighted the necessity of a multidisciplinary caring approach for the family, with a particular focus on critical moments such diagnosis or developmental transitions.

Measuring Moral Distress Among Critical Care Clinicians: Validation and Psychometric Properties of the Italian Moral Distress Scale-Revised.

OBJECTIVES: Moral distress is a common experience among critical care professionals, leading to frustration, withdrawal from patient care, and job abandonment. Most of the studies on moral distress have used the Moral Distress Scale or its revised version (Moral Distress Scale-Revised). However, these scales have never been validated through factor analysis. This article aims to explore the factorial structure of the Moral Distress Scale-Revised and develop a valid and reliable scale through factor analysis. DESIGN: Validation study using a survey design. SETTING: Eight medical-surgical ICUs in the north of Italy. SUBJECTS: A total of 184 clinicians (64 physicians, 94 nurses, and 14 residents). INTERVENTIONS: The Moral Distress Scale-Revised was translated into Italian and administered along with a measure of depression (Beck Depression Inventory-Second Edition) to establish convergent validity. Exploratory factor analysis was conducted to explore the Moral Distress Scale-Revised factorial structure. Items with low (less than or equal to 0.350) or multiple saturations were removed. The resulting model was tested through confirmatory factor analysis. MEASUREMENTS AND MAIN RESULTS: The Italian Moral Distress Scale-Revised is composed of 14 items referring to four factors: futile care, poor teamwork, deceptive communication, and ethical misconduct. This model accounts for 59% of the total variance and presents a good fit with the data (root mean square error of approximation = 0.06; comparative fit index = 0.95; Tucker-Lewis index = 0.94; weighted root mean square residual = 0.65). The Italian Moral Distress Scale-Revised evinces good reliability (α = 0.81) and moderately correlates with Beck Depression Inventory-Second Edition (r = 0.293; p < 0.001). No significant differences were found in the moral distress total score between physicians and nurses. However, nurses scored higher on futile care than physicians (t = 2.051; p = 0.042), whereas physicians scored higher on deceptive communication than nurses (t = 3.617; p < 0.001). Moral distress was higher for those clinicians considering to give up their position (t = 2.778; p = 0.006). CONCLUSIONS: The Italian Moral Distress Scale-Revised is a valid and reliable instrument to assess moral distress among critical care clinicians and develop tailored interventions addressing its different components. Further research could test the generalizability of its factorial structure in other cultures.

Role of psychological factors in burning mouth syndrome: A systematic review and meta-analysis.

Background Burning mouth syndrome (BMS) is a chronic medical condition characterised by hot, painful sensations in the lips, oral mucosa, and/or tongue mucosa. On examination, these appear healthy, and organic causes for the pain cannot be found. Several studies have yielded scant evidence of the involvement of psychological and/or psychopathological factors, and several have outlined a model for the classification of BMS. Aim This review aims to provide a systematic review of research examining the psychological, psychiatric, and/or personality factors linked to BMS. Findings Fourteen controlled studies conducted between 2000 and the present were selected based on stringent inclusion/exclusion criteria. All studies but one reported at least some evidence for the involvement of psychological factors in BMS. Anxiety and depression were the most common and the most frequently studied psychopathological disorders among BMS patients. Discussion and conclusion Anxiety and depression play critical roles in this condition. Evidence on the role of personality characteristics of BMS patients has also been produced by a few studies. Further studies on the role of specific psychological factors in BMS are warranted, but the importance of a multidisciplinary approach (medical and psychological) to BMS is no matter of discussion.

Sudden unexpected death in epilepsy (SUDEP) disclosure in pediatric epilepsy: An Italian survey on "to tell or not to tell".

BACKGROUND AND OBJECTIVES: Although there has recently been significant debate regarding the importance of disclosing the risk of SUDEP, professional societies and clinical practice guidelines currently recommend that the risk of SUDEP be disclosed as part of a comprehensive epilepsy education program. Therefore, the primary aim of the present study was to examine whether healthcare providers treating pediatric patients with epilepsy in Italy would disclose the risk of SUDEP to the parents of children with epilepsy. METHODS: The present study assessed data from a questionnaire that collected sociodemographic information and clinicians' attitudes towards SUDEP. The survey was available online from September to December 2015. Chi-squared (χ2) tests and multivariate logistic regression analysis were performed when appropriate, and a qualitative content analysis of open-ended questions was performed. FINDINGS: A total of 114 medical doctors (71 females and 43 males) completed the questionnaire. Of the respondents, 18 (16.2%) stated that all patients should be counseled about SUDEP, 22 (19.8%) thought that the majority should be, 58 (52.3%) said that only a minority should be, and 13 (11.7%) believed none should be. With respect to physicians' experience in counseling about SUDEP, only 2 (1.8%) counseled all their patients. A univariate logistic regression analysis showed that the factors associated with "not counseling about SUDEP at all" were the low number of patients with epilepsy they took care of (p<0.01), fewer years of experience (p=0.03), and the belief that it was safe from a legal point of view (p<0.001), The main reasons for counseling about SUDEP were refractory course of epilepsy (79%) and if the parent/patient requested information (65%). Additionally, the findings of the qualitative analysis highlighted the emotional difficulties that neuropediatricians encounter when dealing with the disclosure of SUDEP. CONCLUSIONS: The present findings showed that a minority of neuropediatricians in Italy counseled all parents of their patients about SUDEP. Educational training may help physicians better communicate with the patient/parents regarding this difficult issue.

Alexithymia in chronic and episodic migraine: a comparative study.

BACKGROUND: Alexithymia is a term used to describe a disorder where patients have difficulty in expressing their own feelings in words. AIMS: The analysis of alexithymia in patients suffering from chronic migraine (CM) or episodic migraine (EM) compared to healthy controls. METHODS: Two clinical samples formed by 80 CM patients (21 males and 59 females, mean age: 44.65) and 44 EM patients (8 males and 36 females, mean age: 42.18) were enrolled. A group of 67 healthy subjects served as controls (26 males and 41 females, mean age: 41.21). All subjects were requested to fill in the 20-item version of the Toronto Alexithymia Scale (TAS-20). RESULTS: We found a statistically significant difference between groups in Factor 1 (difficulty in describing feelings), F(2, 191) = 7.96, p < 0.001, and in TAS total, F(2, 191) = 5.37, p = 0.005. Post-hoc analyses revealed that CM patients had higher scores in TAS factor 1 and in TAS total than healthy controls. There were no significant differences between CM and EM patients, even if CM sufferers reported a trend towards higher scores in each TAS factor as well as in TAS total. CONCLUSIONS: Alexithymia emerges as a potential characteristic trait of migraine, regardless of disease severity.

Inflammatory bowel diseases and psychological issues: A new approach for a systematic analysis of the academic debate.

Inflammatory bowel disease (IBD) has received increasing attention in recent years within the literature, due to its incidence and prevalence. The pathogenesis of IBD is still unclear, but the research community is increasingly suggesting that psychological issues may play a role in its aetiology and in exacerbation of symptoms. However, the literature regarding the psychological factors associated with IBD remains controversial and fragmented. The aim of the present study is twofold: (1) to identify, through a bibliometric analysis, the current state of the ongoing scientific debate regarding the relationship between IBD and psychological/psychiatric factors; (2) to analyse, through a qualitative software-based thematic analysis, the main themes characterizing the literature on this topic from 1988 to 2012. This study highlighted increasing number of academic publications in recent years regarding the multiplicity of factors related to the disease process in IBD, thus confirming the growing interest in this issue. IBD is becoming increasingly recognized by the medical literature as being exacerbated by a multi-componential process that needs to be studied through a biopsychosocial theoretical perspective which ables to orient multidisciplinary healthcare organizations and clinical interventions aimed at addressing IBD patient needs at different levels. This study also sheds light on two possible theoretical perspectives through which the academic community has considered IBD: A biomedical point of view that addresses the need for an etiological explanation of IBD and a behavioural point of view that aims at describing the observable symptoms and measurable health outcomes of clinical interventions such as patient adherence and engagement in the care and treatment process.

[Italian version of the Defense Mechanisms Rating Scales for Clinicians: a tool for the assessment of defense mechanisms in medical oncology]. / Versione italiana della Defence Mechanisms Rating Scales for Clinicians: uno strumento per la valutazione dei meccanismi di difesa del medico in oncologia.

INTRODUCTION: Facing distress situations arising from the interaction with the patient in oncology, eg breaking bad news, clinicians also, such as patients, protect themselves using unconscious defense mechanisms. Clinicians' psychic defenses topic is related to the clinicians training on communication with patients and to clinicians' individual characteristics issues. For clinicians the defensive functioning can be adaptive when mature defenses are activated or maladaptive if the defensive mode is immature, with implications on medical care effectiveness. It is therefore important to identify, assess and intervene on clinicians' defense mechanisms. The Defense Mechanisms Rating Scales for Clinicians (DMRS-C) is a tool developed as an addendum to the DMRS (originally created by Perry), for the assessment of clinician defenses. It is an assessment tool based on the observer, which can be applied to audio or video recordings, interviews transcripts or medical - psychotherapy sessions. This tool is currently available in French language only. AIM: The aim of this work is to translate and adapt DMRS-C in Italian. METHOD: The DMRS-C has been translated into Italian and back-translated into French in order to verify the correspondence with the original language. Psychometric properties of the scale has been investigated, in terms of face validity and reliability among judges, by calculating the intraclass coefficients Correlation, based on videotaped interviews of oncology visits from the Milan San Paolo Hospital video recordings Archive. RESULTS: The assessment tool has had positive findings for the purposes of intra-judges reliability (ICC=4.73; sd mean=80,33) and face validity. CONCLUSIONS: The consistency of the italian version with the original makes it suitable to highlight the frequency and variety of clinician defenses. This is the first study on medical oncologists defenses in real interviews. This tool will be useful to the fields of training and research on defenses in clinical care settings treating severe conditions such as oncology.

The elephant in the room: a study on the dialogue about sexuality during Assisted Reproductive Technology visits.

Despite ongoing medical advancements in infertility treatment, the significant impact of sexuality on this journey often goes unaddressed. The present research aims to examine sexual conversations during ART visits, including who initiate the conversation and their content.This quali-quantitative study delves into analyzed video-recorded ART visits to explore how "sex" conversations are broached during healthcare interactions. Our findings reveal a strikingly low proportion of utterances related to sexuality, accounting for only 1.3% of the total 14,372 utterances analyzed. Sex utterances were mainly introduced by physicians (72%), while regarding those introduced by the couple, 64% were reported by men. From the qualitative analysis on the utterances emerged three distinct levels of communication about sex: explicit, almost explicit, and implicit. While physicians and males exhibit an almost balanced distribution across the 3 levels, female patients primarily respond to explicit and almost explicit communication initiated by physicians. The low percentage of sexual utterances underscores the rarity of these conversations during ART interactions, despite the clinical field where sexual health should deserve a crucial attention. Opening the door to conversations about sexuality could help to create a safe and supportive space for patients to talk about sex, with a potential impact on well-being and quality of care during the ART process.

[Management of patients with chronic pain: emerging perspectives and current practices.] / La gestione del paziente con dolore cronico: prospettive emergenti e pratiche attuali.

According to the International association for the study of pain (Aisd), chronic pain is «an unpleasant sensory and emotional experience associated with, or resembling, ongoing, or potential tissue damage¼. The evolution of the definition of chronic pain has recognized the centrality of subjective and multidimensional valence, involving biological, psychological, and social aspects. Hence, there is a need to introduce patient-centered medicine and broaden the chronic pain management modalities. The primary clinical goal purpose does not end with the biological dimension and treatment of pain but should include the patient's individual experience and maintain an interdisciplinary value, including pharmacological therapy, as well as psychological care and integrative interventions. The perspectives illustrated provided the theoretical rationale for the organization of the Pain Clinic at Asst Santi Paolo e Carlo University Hospitals in Milan. The articulation of this care pathway can serve as a model, which can be applied to other clinical settings, where an interdisciplinary and multimodal approach is needed.

Impact of psychological intervention on anxiety, depression, and post-traumatic stress disorder: results from a longitudinal study of hospitalized Covid-19 patients.

OBJECTIVE: Hospitalization for Covid-19 has been recognized as a potentially traumatic experience. This longitudinal cohort study assessed the impact of psychological intervention for Covid-19 patients on anxiety, depression, and post-traumatic stress disorder (PTSD). MATERIALS AND METHODS: Of 386 Covid-19 patients enrolled, 127 completed HADS and PCL-5 questionnaires at 2 months (T1), 6 months (T2) and 12 months (T3) after hospital discharge. Between T1 and T2, patients were offered the opportunity to receive psychological intervention: 92 did not request any psychological support (No support group), 15 received only one psychological consultation (Consultation group) and 20 received longer psychological support (Support group). Mixed ANOVAs were used to assess the psychological symptoms of the 3 Groups over Time. RESULTS: The No support group reported lower anxiety, depression, and PTSD than the other two groups. Anxiety and PTSD increased over time across groups. A Time x Group interaction was found for depression (F(2.124)=3.72, p<.05, pη2=.06). The Support group reported a decrease in depression from T1 (M=7.85) to T2 (M=7.05) and an increase from T2 to T3 (M=8.05), although not significant. The No support (T1 M=2.84; T3 M=4.36; p<.001) and the Consultation groups (T1 M=4.73; T3 M=6.33; p<.05) reported an increase in depression from T1 to T3. CONCLUSIONS: Psychological interventions were appropriately allocated to patients with more severe symptoms. Most of the patients did not request psychological intervention. Long-term psychological support may have helped Covid-19 patients to contain depressive symptoms over time.

Association between tight junction proteins and cognitive performance in untreated persons with HIV.

BACKGROUND: HIV-associated neurocognitive disorders (HAND) still affects persons with HIV (PWH) and their pathogenesis is not completely understood. We aimed to explore the association between plasma and cerebrospinal fluid (CSF) markers of blood-brain barrier (BBB) impairment and HAND in untreated PWH. DESIGN: Cross-sectional study. METHODS: We enrolled untreated PWH, who underwent blood examinations and lumbar puncture to measure inflammation (IL-15, TNF-α), BBB damage (zonulin and tight junction proteins, tight junction proteins: occludin, claudin-5) and endothelial adhesion molecules (VCAM-1, ICAM-1). A comprehensive neurocognitive battery was used to diagnose HAND (Frascati criteria). RESULTS: Twenty-one patients (21/78, 26.9%) patients presented HAND (100% ANI). HAND patients displayed more frequently non-CNS AIDS-defining conditions, lower nadir CD4 + T cells and increased CD4 + T-cell exhaustion (lower CD4 + CD127 + and CD4 + CD45RA + T-cell percentages), in comparison to individuals without cognitive impairment. Furthermore, HAND was characterized by higher plasma inflammation (IL-15) but lower CSF levels of biomarkers of BBB impairment (zonulin and occludin). The association between BBB damage with HAND was confirmed by fitting a multivariable logistic regression. CSF/plasma endothelial adhesion molecules were not associated with HAND but with a poor performance in different cognitive domains. CONCLUSION: By showing heightened inflammation and BBB impairment, our study suggests loss of BBB integrity as a possible factor contributing to the development of HAND in untreated PWH.

Psychological factors in functional hypothalamic amenorrhea: A systematic review and meta-analysis.

Background: Psychological factors have been found to be associated with functional hypothalamic amenorrhea (FHA); however, their role in the onset or persistence of FHA is still understudied. The study aims to assess the associations of psychological factors with the presence vs the absence of FHA. Methods: A systematic literature search has been conducted across the major databases (PubMed, PsycINFO, Scopus, and Embase) to explore the psychological factors associated with FHA. The search was limited to English-written articles published from 2000 onwards. Articles were selected based on stringent inclusion/exclusion criteria. After data extraction, meta-analysis and meta-synthesis were conducted. Results: Of 349 retrieved articles, eight studies were included. Findings indicate that the main psychological factors associated to FHA seem to be depression and eating attitudes, especially drive for thinness. FHA women present higher levels of anxiety, sleep disorders, dysfunctional attitudes, and alexithymia. The meta-analysis on drive for thinness revealed that the pooled MD across the studies was statistically significant both in the fixed 0.63 (95% CI: 0.31-0.95) and random model 0.70 (95% CI: 0.13-1.26). Likewise, as for depression, the pooled MD across the studies was statistically significant both in the fixed 0.60 (95% CI: 0.36-0.84) and random model 0.61 (95% CI: 0.20-1.01). Discussion: Findings showed the association of psychological factors and FHA and recognized their involvement in the persistence of the disorder. A multidisciplinary approach should involve a collaborative process between gynecologists, clinical psychologists, and psychiatrists, from diagnosis to treatment. Longitudinal studies should be implemented with a comparison/control group or by including clinical psychologists in the psychological assessment and study design.

Long COVID in Children: A Multidisciplinary Review.

Long COVID syndrome has emerged as a long-lasting consequence of acute SARS-CoV-2 infection in adults. In addition, children may be affected by Long COVID, with potential clinical issues in different fields, including problems in school performance and daily activities. Yet, the pathophysiologic bases of Long COVID in children are largely unknown, and it is difficult to predict who will develop the syndrome. In this multidisciplinary clinical review, we summarise the latest scientific data regarding Long COVID and its impact on children. Special attention is given to diagnostic tests, in order to help the physicians to find potential disease markers and quantify impairment. Specifically, we assess the respiratory, upper airways, cardiac, neurologic and motor and psychological aspects. Finally, we also propose a multidisciplinary clinical approach.