A theoretical model of asymmetric wave ripples.

The time development of ripples under sea waves is investigated by means of the weakly nonlinear stability analysis of a flat sandy bottom subjected to the viscous oscillatory flow that is present in the boundary layer at the bottom of propagating sea waves. Second-order effects in the wave steepness are considered, to take into account the presence of the steady drift generated by the surface waves. Hence, the work of Vittori & Blondeaux (1990 J. Fluid Mech. 218, 19-39 (doi:10.1017/S002211209000091X)) is extended by considering steeper waves and/or less deep waters. As shown by the linear analysis of Blondeaux et al. (2000 Eur. J. Mech. B 19, 285-301 (doi:10.1016/S0997-7546(90)00106-I)), because of the presence of a steady velocity component in the direction of wave propagation, ripples migrate at a constant rate that depends on sediment and wave characteristics. The weakly nonlinear analysis shows that the ripple profile is no longer symmetric with respect to ripple crests and troughs and the symmetry index is computed as a function of the parameters of the problem. In particular, a relationship is determined between the symmetry index and the strength of the steady drift. A fair agreement between model results and laboratory data is obtained, albeit further data and analyses are necessary to determine the behaviour of vortex ripples and to be conclusive.

Diffusion tensor imaging and tractography to evaluate sacral nerve root abnormalities in endometriosis-related pain: a pilot study.

OBJECTIVE: To prospectively evaluate microstructural abnormalities in sacral nerve roots in women affected by chronic pelvic pain associated with endometriosis. METHODS: We enrolled 30 women with an ultrasound diagnosis of endometriosis and moderate-severe chronic pelvic pain; 10 age-matched healthy women comprised the control group. All subjects underwent 3 T magnetic resonance imaging (MRI), including diffusion tensor imaging (DTI); the sacral roots were reconstructed by post-processing the DTI data with dedicated software. Mean fractional anisotropy (FA) values in the S1, S2 and S3 roots were quantified. Analysis of FA values was performed by two radiologists in order to evaluate the interobserver agreement. RESULTS: The sacral nerve roots in healthy subjects were clearly visualised. Most of the patients with endometriosis displayed abnormalities of S1, S2 and S3 bilaterally at tractography, including an irregular and disorganised appearance. FA values in the S1, S2 and S3 roots were significantly lower in patients than in controls (P < 0.0001, <0.05 and <0.02, respectively) for both observers. No significant difference was found between observers. CONCLUSION: DTI with tractography is a non-invasive means of detecting changes in the microarchitecture of the sacral nerve roots. It can qualitatively and quantitatively reveal sacral root abnormalities in patients with endometriosis-associated pain. KEY POINTS: • MRI is increasingly used for endometriosis and chronic pelvic pain (CPP). • Magnetic resonance tractography can demonstrate microarchitectural abnormalities in sacral nerve roots. • Tractography shows altered microstructure of sacral roots affected by endometriosis and CPP. • S1-S3 fractional anisotropy values are lower in endometriosis than in healthy women. • Sacral nerve root alteration may explain the nature of endometriosis-related CPP.

[Effect on skin and hormonal hyperandrogenic manifestations of an oral estroprogestin association containing ethynilestradiol 30 mg and drospirenone 3 mg]. / Effetto sulle manifestazioni iperandrogeniche a livello cutaneo ed ormonale dell'associazione orale estroprogestinica contenente Etinilestradiolo 30 mg e Drospirenone 3 mg.

AIM: This study evaluated hormonal and skin effects in hyperandrogenic women of an oral estroprogestin (EP) association containing ethynilestradiol 30 mcg plus drospirenone 3 mg. METHODS: Thirty two women with signs and symptoms of hyperandrogenism (seborrhea, acne, increased hair); hormonal assessment (follicle-stimulating hormone, [FSH]; luteinizing hormone, LH; 17-hydroxi-progesterone, 17OHP; androstenedione, A, testosterone, T; dehydroepiandrosterone sulfate, DHEAS; sex hormone binding globulin, [SHBG]; Free Androgen Index [FAI, Tx100/SHBG] was performed before the start of treatment, and after 3 and 6 months of administration of EP. The impact on seborrhea, acne, and hair pattern (Ferriman-Gallwey score) was assessed, and, by non-invasive technique, hydration, water transpiration, and homogeneity of the skin were evaluated. RESULTS: Treatment with this EP for 6 months decreased significantly circulating androgen levels (A, T, DHEAS) and FAI, and increased SHBG levels, also reducing seborrhea, acne and hirsutism. Moreover, EE/DRSP increased hydration and improved overall appearance of skin surface (homogeneity). CONCLUSION: Treatment with EE 30 mcg+DRSP 3 mg improves hormonal pattern and skin appearance in hyperandrogenic patients, potentially with subsequent, beneficial effects on quality of life of these women.

Simple enucleation for the treatment of highly complex renal tumors: Perioperative, functional and oncological results.

AIM: To assess the role of simple enucleation (SE) for the treatment of highly complex renal tumors. METHODS: Overall, 96 Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score 10 to 13 renal tumors were treated with SE at our institution. All conventional perioperative variables, surgical, functional and oncological results were gathered in a prospectively maintained database. Survival curves were generated using a Kaplan-Meier method. Univariate analysis assessed the outcome differences. RESULTS: Mean (± 1s.d.) clinical tumor diameter was 4.8 (± 1.6 cm). 70.8% of patients had ≥ cT1b stage. The PADUA score was recorded as 10, 11, 12 and 13 in 57.3%, 29.2%, 11.5%, and 2.1% of tumors respectively. Overall, 76 patients were treated with an open approach and 20 robotically. Mean warm ischemia time (WIT) was 19.2 min, and WIT greater than 25 min occurred in 14.6% of cases. Positive surgical margin (PSM) rate was 3.6% and trifecta was achieved in 64.3% of patients. Postoperative surgical complications occurred in 24% of patients, with 14.6% Clavien-Dindo grade 1-2, 8.3% grade 3, and 1% grade 4. Five-year cancer specific survival (CSS), recurrent free survival (RFS), and overall survival (OS) rates resulted 96.1%, 90.8% and 88.0%, respectively. Overall, 4.2% of patients experienced progressive disease. At follow-up, the mean decrease of eGFR from preoperative value was 13.9 ml/min. This was not significantly correlated with PADUA score (p = 0.69). The surgical approach was neither a predictor of Trifecta outcome, nor of postoperative complications, WIT > 25 min or PSM rate. CONCLUSIONS: SE is an effective treatment for highly-complex renal tumors, with a potential key role to widen the NSS (nephron sparing surgery) indications according to guidelines.

Outpatient hysteroscopy in the diagnosis of neoplastic and preneoplastic lesions of the endometrium.

The results of a study performed on a case series of 250 women treated in our out-patient department for abnormal uterine bleeding are reported. Half of these patients (125) were 45 years of age or over and therefore at risk of adenocarcinoma or endometrial hyperplasia while the other half were under 45 years of age. All the patients were submitted to hysteroscopic examination as out-patients (no important side-effects occurred), together with cytologic and/or histological examination of the endometrium. This procedure revealed no disease in 59 cases (23.6%) and the presence of one or more benign conditions in 188 patients (75.2%) (inflammation, polyposis, myomatosis, endocervical or uterine adenomiosis, endometrial hyperplasias, dysfunctional patterns, intrauterine foreign bodies). Endometrial adenocarcinoma was diagnosed in 3 patients (1.2%). The discovery of 3 cases (1.2%) of adenocarcinomas and 62 cases (24.8%) of endometrial hyperplasias (58 simple glandular hyperplasia, 3 cystic-glandular hyperplasias and 1 polypoid hyperplasia) emphasive the reliability of hysteroscopy in the diagnosis of endometrial neoplasias and their precursors.

Analysis of the prognostic factors of endometrial carcinoma. A retrospective study of 144 patients.

One hundred and fourty-four patients with endometrial carcinoma who had undergone surgery as primary treatment were retrospectively studied from January 1980 to September 1990 for the purpose of correlating the survival rate with known or presumed prognostic factors. The patients averaged 63.1 years of age (range 32-88 years); 106 were classified as having Stage I disease, 10 Stage II, 16 Stage III and 2 Stage IV. Histology confirmed pure adenocarcinomas in 77%, adenosquamous carcinoma in 3.5%, clear cell carcinomas in 2.5% and serous papillary in 17%. Surgical treatment consisted of extrafasial hysterectomy with pelvic lymphadenectomy up to the aortic bifurcation in 69 patients (48%), Wertheim's hysterectomy in 10 (7%), simple or vaginal hysterectomy in the remaining 65 patients (45%). Five-year survival rate in all the case series was 74.3% whereas for patients with Stage I carcinoma it was 79.9%. Different prognostic factors were correlated in a multivariate analysis with the outcome of the disease. Myometrial invasion presented a mortality ODDS RATIO (OR) of 3.18 (95% CI 1.25-8.06), for histologic grade OR 4.33 (95% CI 1.74-10.74) and for stage (2-3 vs 1) OR of 2.73 (95% CI 1.09-6.83) demonstrating a high significance, whereas pregnancy, excess body weight, age and histotype were not considered as relevant factors for prognosis. For age we found mortality OR 2.54 (95% CI 0.75-8.59) for women greater than 55y.

A new surveillance gynecological network to assess the incidence and prevalence of genital warts in the Italian female population: lessons learned.

Human papillomavirus (HPV) is the etiologic agent of genital warts. Genital warts are transmitted through sexual contacts and caused in about 90% of the cases by HPV types 6 and 11. Worldwide, several million cases of genital warts occur each year both in females and males. In Italy, genital warts are not subject to mandatory notification; the only available data come from the sentinel surveillance system for sexually transmitted infections (STI), which show that external genital warts represent the most frequent STI in Italy. However, these data are not suitable for estimates of incidence and prevalence of single STI in the general population. To obtain more reliable data on the epidemiology of genital warts in the female population at large, we implemented a network of local gynecologists reporting essential data on all women visited throughout one year and detailed data on women who were diagnosed with genital warts. In order to organize and create this network, a partnership between the Italian National Institute of Health and the Italian Society of Gynecology and Obstetrics was constituted to implement the start-up and management of this pilot and unique project in Europe. The present paper intends to present the methods used to build and implement this surveillance network of local gynecologists.

Feasibility of 3.0T pelvic MR imaging in the evaluation of endometriosis.

INTRODUCTION: Endometriosis represents an important clinical problem in women of reproductive age with high impact on quality of life, work productivity and health care management. The aim of this study is to define the role of 3T magnetom system MRI in the evaluation of endometriosis. MATERIALS AND METHODS: Forty-six women, with transvaginal (TV) ultrasound examination positive for endometriosis, with pelvic pain, or infertile underwent an MR 3.0T examination with the following protocol: T2 weighted FRFSE HR sequences, T2 weighted FRFSE HR CUBE 3D sequences, T1 w FSE sequences, LAVA-flex sequences. Pelvic anatomy, macroscopic endometriosis implants, deep endometriosis implants, fallopian tube involvement, adhesions presence, fluid effusion in Douglas pouch, uterus and kidney pathologies or anomalies associated and sacral nervous routes were considered by two radiologists in consensus. Laparoscopy was considered the gold standard. RESULTS: MRI imaging diagnosed deep endometriosis in 22/46 patients, endometriomas not associated to deep implants in 9/46 patients, 15/46 patients resulted negative for endometriosis, 11 of 22 patients with deep endometriosis reported ovarian endometriosis cyst. We obtained high percentages of sensibility (96.97%), specificity (100.00%), VPP (100.00%), VPN (92.86%). CONCLUSION: Pelvic MRI performed with 3T system guarantees high spatial and contrast resolution, providing accurate information about endometriosis implants, with a good pre-surgery mapping of the lesions involving both bowels and bladder surface and recto-uterine ligaments.

Multiple ipsilateral renal tumors: retrospective analysis of surgical and oncological results of tumor enucleation vs radical nephrectomy.

AIMS: To evaluate the role of nephron-sparing surgery (NSS) compared to radical nephrectomy (RN) for treating multiple ipsilateral renal tumors. METHODS: We retrospectively reviewed the clinical and pathological data of 960 patients who had surgery for pathologically confirmed RCC between 1986 and 2006. Thirty-four patients were diagnosed as having at least one ipsilateral smaller solid lesion associated with the primary RCC: 22 had RN while 12 had NSS for tumor enucleation. RESULTS: All patients who had NSS had tumors confined within the kidney, as did 82% of patients treated with RN. The sole presence of concomitant accompanying benign histology to the primary RCC was diagnosed in 20% of patients. The mean (median, range) follow-up for patients treated with RN and NSS was 69 (58, 12-214) and 58 (44, 12-151) months. Tumor stage was significantly associated with tumor-specific survival (TSS) in the RN group (p<0.001). None of the patients who had tumor enucleation had positive surgical margins. Two patients recurred locally after NSS, elsewhere in the kidney, resulting in a crude ipsilateral recurrence rate of 17%. The analysis of TSS for patients with multiple ipsilateral tumors with a pT1 primary lesion showed no statistically significant differences between patients who had RN or NSS. Two patients had contralateral recurrence, resulting in a crude rate of 6%. CONCLUSIONS: For patients with multiple ipsilateral renal tumors, 20% of the satellite lesions are benign and 6% develop a contralateral metachronous recurrence. We also observed similar TSS for patients treated with NSS and RN.

Treatment patterns and associated costs for genital warts in Italy.

OBJECTIVE: Genital warts are caused by human papillomavirus (HPV), principally types 6 and 11, and are highly contagious. This study assessed treatment patterns and costs of management of genital warts in Italy. RESEARCH DESIGN AND METHODS: This was a retrospective, observational study conducted among gynaecologists, dermatologists, and specialists at sexually transmitted disease clinics in Italy. Resource-use data related to genital warts were collected for patients at risk in the age range 14-64 years examined during 2005. Unit costs were assigned to resource use to provide estimates of the direct, indirect and total costs per case of genital warts. RESULTS: Twenty-eight investigators enrolled 341 patients aged 15-64 years, including 194 (56.9%), 81 (23.7%) and 66 (19.4%) patients with newly diagnosed, recurrent and resistant genital warts, respectively. Most patients (333/341; 97.7%) had at least one outpatient visit, while 43 (12.6%) patients were hospitalised, including 39 patients without an overnight stay (day-hospital cases, 11.4%). Self-applied medication was prescribed for 124 (36.4%) patients. Most outpatient cases (267/333; 80.2%) underwent an office-based procedure. Mean annual direct medical costs per patient, which were funded predominantly by the Italian National Health Service (there was some patient co-payment), were €242 for men and €332 for women. When productivity losses were included, mean total annual costs were €325 for men and €464 for women. CONCLUSIONS: This is the first study of treatment patterns and costs for genital warts in Italy. Treatment patterns differ in some respects from those observed in other European countries, but costs generally appear similar. Despite the limitations of physician selection bias and over-representation of North Italy in the patient sample, the findings of this study may be useful in estimating the cost-effectiveness of introducing a quadrivalent HPV vaccination programme in Italy.

PSA recurrence after brachytherapy for seed misplacement: a double-blind radiologic and pathologic work-up after salvage prostatectomy.

A 64-year-old man was treated with brachytherapy for prostate cancer. Prostate-specific antigen (PSA) nadir was achieved at 3 months, while at 24 months PSA increased to 18.7 ng ml(-1). Re-biopsy and imaging revealed locally recurrent prostate carcinoma without metastasis. The patient was treated with salvage radical prostatectomy, and the surgical specimen underwent double-blind evaluation with RX scan and whole-mount histopathology sections. Radiology revealed an area without any seeds in the right base of the prostate, and pathologic assessment demonstrated adenocarcinoma involving the right base of the gland. This case is indicative of tumor relapse occurring for seed migration after good initial positioning.

Endometrial lymphoepitheliomalike carcinoma: absence of Epstein-Barr virus genomes.

The aim of this study was to report a case of primary lymphoepitheliomalike endometrial carcinoma (FIGO stage IB). A 57-year-old woman presented with an endometrial tumor showing the classic clinical and hysteroscopic aspects of endometrial carcinoma. Morphologically, the neoplasm was similar to undifferentiated nasopharyngeal carcinoma (lymphoepithelioma). Immunohistochemistry showed that the tumor cells were cyokeratins and epithelial membrane antigen positive. Leucocyte common antigen, estrogen and progesterone receptors, neuron specific enolase, cromogranin, synaptophysin, and p53 were negative. We did not find evidence of Epstein-Barr virus (EBV) infection using immunohistochemistry and polymerase chain reaction (PCR). We report the third case of an endometrial lymphoepitheliomalike carcinoma (LELC). The patient did not receive chemotherapy and is alive and free of disease 24 month after diagnosis. LELC can occur in the endometrium and in this location may not be associated with EBV infection.

Operative Laparoscopy for Adnexal Cystic Masses in Patients Under 40 Years of Age

From January 1990 through October 1993, 527 patients under 40 years were submitted to operative laparoscopy for the treatment of 544 adnexal cystic masses by stripping or vaporization/coagulation techniques in nine centers in Rome. The mean age of patients was 27.8 years, ranging from 13 to 39. The mean diameter of the cysts was 45.8 mm. ranging from 20 to 130. The procedure was completed by laparoscopy in 518 cases (95.2%) whereas 26 cases (4.8%) were converted to laparotomy. Conservative treatment was performed in all cases except 6 (1.1%), where ovariectomy or adnexectomy was performed. Histopathology revealed a borderline tumor in two; in all others the cyst was benign. It is concluded that operative laparoscopy is the procedure of choice for the treatment of carefully selected adnexal masses in patients of reproductive age.

Operative Laparoscopy for the Treatment of Ovarian Dermoids

From January 1, 1991, to October 31, 1993, 67 patients with a histologic diagnosis of benign cystic teratoma were treated by operative laparoscopy in nine centers in Rome. The mean age of patients was 29.7. years, ranging from 16 to 45 years. The mean diameter of the cysts was 41.6 mm, ranging from 20 to 120 mm. The procedures were completed by laparoscopy in 62 cases (92.5%) whereas 5 cases were converted to laparotomy. Conservative treatment was performed in all cases except seven cases (10.44%), where ovariectomy was performed. No recurrences occurred in all patients, with a follow-up of at least 3 months. We conclude that operative laparoscopy can be considered a valid alternative to classic laparotomy for dermoid cysts.