Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis.

BACKGROUND: Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective. OBJECTIVES: To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected. DESIGN: Systematic review with network meta-analysis (PROSPERO:CRD42021250651). DATA SOURCE: PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021). ELIGIBILITY CRITERIA: All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction. RESULTS: Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40). CONCLUSION: All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone. TRIAL REGISTRATION: PROSPERO (CRD4202125065).

Determinants of low measles vaccination coverage in children living in an endemic area.

Measles outbreaks were recently reported in Europe due to low immunization rates. In this scenario, identifying the reasons of no vaccination is crucial to set up strategies to improve immunization rate. A cross-sectional study was conducted to investigate the determinants of missed vaccination in children living in Southern Italy, during the 2016 outbreak. A standardized face-to-face questionnaire was used to record demographic data, immunization status, and reasons for missed vaccination. A total of 1141 children (median age 86 months, male 47.2%) was enrolled, 77.8% of the children were adequately vaccinated for age, 6.3% were incompletely vaccinated for age, and 15.9% did not receive any vaccine dose. Vaccination rate and reasons for not vaccinating significantly varied according to age, with children ≤ 24 months showing the lowest rate (67.8%). Reasons for not vaccinating included fear for side effects (51%), presence of underlying chronic conditions (12.2%), skip scheduled appointment (12.2%), refusal of vaccination (10.3%), acute illnesses (7.2%), and allergy to eggs (4.6%). The presence of underlying condition was a risk factor for inadequate immunization (p < 0.0001). Only 4.7% of conditions were true contraindications to vaccine administration.Conclusion: We reported inadequate measles immunization rate in Southern Italy, with lowest rates in children ≤ 2 years or with underlying conditions. Only a minority had true contraindications to vaccine uptake. Implementation strategies addressed to health-care professionals and families should focus on the reported determinants to increase measles vaccination coverage. What is Known: • Measles is a viral, highly communicable disease, preventable by vaccine. • Measles elimination in Europe failed as demonstrated by outbreaks in several countries, due to low immunization rates. What is New: • Inadequate measles immunization rate due to false contraindications in Southern Italy, with lowest rates in children ≤ 2 years. • The presence of underlying disease is a risk factor for inadequate immunization.

Maternal serum PAPP-A as an early marker of obstetric complications?

OBJECTIVE: The aim of this study was to investigate whether low first-trimester PAPP-A levels are associated with an adverse pregnancy outcome. MATERIALS AND METHODS: A retrospective case-control study was carried out using a Down's syndrome assays database over a 6-year period, between the 8th and 11th week of pregnancy. There were 164 women with PAPP-A multiples of median (MoM) levels <0.3 and 1,640 women with PAPP-A MoM levels ≥0.3 who served as a control group. Outcome measures were the prevalence of miscarriages, gestational hypertension, preeclampsia, pre-term delivery, gestational diabetes and intrauterine growth retardation in both groups. RESULTS: The two groups significantly differed only for miscarriages: 29 (17.7%) vs. 159 (9.7%), p = 0.04, OR 1.7; gestational hypertension: 15 (9.1%) vs. 74 (4.5%), p = 0.02, OR 2.1, and preeclampsia: 9 (5.5%) vs. 29 (1.8%), p = 0.02, OR 2.5. DISCUSSION: Even if in this study the PAPP-A cutoff considered was lower and was assayed in an earlier period compared with other studies, the detection rate for adverse pregnancy outcomes did not improve.

Uncertainty in tuberculosis clinical decision-making: An umbrella review with systematic methods and thematic analysis.

Tuberculosis is a major infectious disease worldwide, but currently available diagnostics have suboptimal accuracy, particularly in patients unable to expectorate, and are often unavailable at the point-of-care in resource-limited settings. Test/treatment decision are, therefore, often made on clinical grounds. We hypothesized that contextual factors beyond disease probability may influence clinical decisions about when to test and when to treat for tuberculosis. This umbrella review aimed to identify such factors, and to develop a framework for uncertainty in tuberculosis clinical decision-making. Systematic reviews were searched in seven databases (MEDLINE, CINAHL Complete, Embase, Scopus, Cochrane, PROSPERO, Epistemonikos) using predetermined search criteria. Findings were classified as barriers and facilitators for testing or treatment decisions, and thematically analysed based on a multi-level model of uncertainty in health care. We included 27 reviews. Study designs and primary aims were heterogeneous, with seven meta-analyses and three qualitative evidence syntheses. Facilitators for decisions to test included providers' advanced professional qualification and confidence in tests results, availability of automated diagnostics with quick turnaround times. Common barriers for requesting a diagnostic test included: poor provider tuberculosis knowledge, fear of acquiring tuberculosis through respiratory sampling, scarcity of healthcare resources, and complexity of specimen collection. Facilitators for empiric treatment included patients' young age, severe sickness, and test inaccessibility. Main barriers to treatment included communication obstacles, providers' high confidence in negative test results (irrespective of negative predictive value). Multiple sources of uncertainty were identified at the patient, provider, diagnostic test, and healthcare system levels. Complex determinants of uncertainty influenced decision-making. This could result in delayed or missed diagnosis and treatment opportunities. It is important to understand the variability associated with patient-provider clinical encounters and healthcare settings, clinicians' attitudes, and experiences, as well as diagnostic test characteristics, to improve clinical practices, and allow an impactful introduction of novel diagnostics.

Pediatric Lyme Disease in Northern Italy: An 18-Year Single-Center Case Series.

Tracing the profile of pediatric Lyme borreliosis (LB) in Europe is difficult due to the interregional variation in its incidence and lack in notifications. Moreover, the identification of LB can be challenging. This study is an 18-year case series of 130 children and adolescents aged under 18 years referred to the Pediatric Infectious Diseases Unit at L. Sacco Hospital, Milan, with suspicion of LB, between January 2005 and July 2023. The routine serological workup consisted of a two-step process: an initial screening test followed by Western blot (WB). Forty-four (34%) patients were diagnosed with LB. The median age was six years, and 45% were females. Of the children with erythema migrans (EM), 33 (57%) were confirmed as having true EM, and, of these, 4 (12%) were atypical. Ten (23%) patients had early disseminated/late diseases, including facial nerve palsy (n = 3), early neuroborreliosis (n = 1), arthritis (n = 3), relapsing fever (n = 2), and borrelial lymphocytoma (n = 1). No asymptomatic infections were documented. Over seventy percent of confirmed LB cases (n = 31/44) recalled a history of tick bites; in this latter group, 19 (61%) were from the area of the Po River valley in Lombardy. Almost half of the children evaluated for LB complained of non-specific symptoms (fatigue, musculoskeletal pain, skin lesions/rash, and persistent headache), but these symptoms were observed in only two patients with confirmed LB. Most LB cases in our study were associated with EM; two-tier testing specificity was high, but we found frequent non-adherence to international recommendations with regard to the timing of serology, application of the two-step algorithm, and antibiotic over-prescription. Most children were initially assessed for a tick bite or a skin lesion suggestive of EM by a family pediatrician, highlighting the importance of improving awareness and knowledge around LB management at the primary healthcare level. Finally, the strengthening of LB surveillance at the national and European levels is necessary.

Pediatric Tuberculosis Diagnostics: Present and Future.

The current diagnostic abilities for the detection of pediatric tuberculosis are suboptimal. Multiple factors contribute to the under-diagnosis of intrathoracic tuberculosis in children, namely the absence of pathognomonic features of the disease, low bacillary loads in respiratory specimens, challenges in sample collection, and inadequate access to diagnostic tools in high-burden settings. Nonetheless, the 2020s have witnessed encouraging progress in the area of novel diagnostics. Recent WHO-endorsed rapid molecular assays hold promise for use in service decentralization strategies, and new policy recommendations include stools as an alternative, child-friendly specimen for testing with the GeneXpert assay. The pipeline of promising assays in mid/late-stage development is expanding, and novel pediatric candidate biomarkers based on the host immune response are being identified for use in diagnostic and triage tests. For a new test to meet the pediatric target product profiles prioritized by the WHO, it is key that the peculiarities and needs of the hard-to-reach pediatric population are considered in the early planning phases of discovery, validation, and implementation studies.

Gastrointestinal Diseases in Children Living with HIV.

Thanks to the advances in antiretroviral therapies (ART) and early diagnosis, pediatric HIV has turned into a chronic infection that requires the collaboration of all pediatric subspecialists for holistic patient management. Gastrointestinal complaints are a frequent reason for seeking access to medical care in all pediatric patients worldwide. Intestinal involvement is present in virtually all children with HIV infections. In high-prevalence settings, up to 25% of children accessing the hospital for diarrhea are diagnosed with HIV. More than half of patients with advanced disease present with gastrointestinal symptoms, from mild infectious diarrhea to severe gastrointestinal impairment, malabsorption and failure to thrive. Gastrointestinal disorders do not spare children on ART, particularly in the initial months of therapy. ART-associated pancreatitis and hepatitis are rare but potentially severe adverse events, whereas lower abdominal symptoms have been reported in more than a third of patients. The latter are usually mild and transient, but may limit ART adherence; a correct framing of the problem is necessary to minimize therapy switches while optimizing the quality of life of children on ART. This review aims to provide state-of-the-art guidance for the initial approach to gastrointestinal diseases in children living with HIV.

Diarrhea in Children with Plasmodium falciparum Malaria: A Case-Control Study on the Prevalence and Response to Antimalarial Treatment.

The role of Plasmodium in the etiology of acute diarrhea in developing countries remains controversial, and gastrointestinal (GI) symptoms are inconsistently reported in malaria. In this observational case-control study, we investigated the prevalence and risk factors for GI symptoms in hospitalized malarious children aged 1 month to 5 years in northern Uganda. Children with a diagnosis of Plasmodium falciparum malaria were enrolled as cases, and feverish children in whom malaria was excluded were enrolled as controls. Among 451 malarious children, 46.1% had GI symptoms at admission. Compared with controls, the frequency of diarrhea (24.8% versus 11.2%, P < 0.001) and vomiting (35.5% versus 17.5%, P < 0.001) was significantly higher in children with malaria, who had a higher chance of showing either vomiting (odds ratio [OR]: 3.22; 95% CI: 2.14-4.91) or diarrhea (OR: 3.14; 95% CI: 1.99-5.07) at hospital admission. A subgroup analysis performed in children with severe malaria, severe anemia, or high-grade fever confirmed these results. Diarrhea was more frequent in infants and children younger than 3 years than in older children. The analysis of 71 malarious children with diarrhea who received intravenous artesunate showed that the symptom resolved within the first 24 hours since the beginning of the treatment in 85.9% of cases. The 3-fold higher prevalence of diarrhea and vomiting in malarious children compared with febrile controls may provide rationale for incorporating malaria testing in the symptom-guided diagnostic approach of the young child with diarrhea and vomiting in malaria-endemic settings.

The Transition of Care From Pediatric to Adult Health-Care Services of Vertically HIV-Infected Adolescents: A Pilot Study.

Objective: Clinical and psychological HIV-related problems peak during adolescence, which coincides with transition of children and adolescents infected from mothers from pediatric to adult reference centers for HIV infection. Transition often is done without specific programs. We wanted to explore transition as an opportunity to increase the efficacy of care and the psychological well-being through a specific program. Methods: Thirteen vertically infected patients aged 13-20 years were followed up for 24 months by pediatricians, infectious disease specialists, a psychologist, and a nurse. Interventions consisted in joint clinic, simplification of therapy, patient group discussions, HIV infection explanations, and psychological support, lasting 12 months. Efficacy was measured by viro-immunological outcomes and adherence to therapy and psychological tests. Clinical, viro-immunological, and psychological evaluations were performed at 0 (T0) and 12 months (T12) and 6 months after transition to an adult center (T18). Psychological outcomes were assessed using standardized questionnaires for quality of life and self-esteem. Results: In 11/13 participants, pills administrations/day were significantly reduced. Patients with undetectable viral load and CD4+ >25% increased from 61 to 77% and from 61 to 74%, respectively. Six months after transition, all patients exhibited an undetectable viral load. Adolescents' awareness of the severity of the disease and the risk of sexual transmission was generally poor. Patients classified with "severe" psychological distress according to the quality of life index decreased from 38 to 15% and well-being increased. Similar results were observed 6 months after the transition to adult care. No effect was observed on self-esteem index. Conclusions: Specific protocols for transition should be developed to optimize resilience and psychological well-being, including routine psychological support for adolescents with HIV infection transiting from pediatric to adult centers for HIV infection.

Effects of adenomyosis on obstetric outcomes.

INTRODUCTION: Several studies investigated the correlation between adenomyosis and adverse pregnancy outcomes. However, the role of adenomyosis as a risk factor for adverse outcomes has yet to be established. The aim of this systematic review is to clarify the possible association between uterine adenomyosis and poor obstetrical outcomes. EVIDENCE ACQUISITION: Numerous studies have demonstrated that adenomyosis increased miscarriage rate, preterm birth and preterm premature rupture of membranes. We conducted a systematic review on the effects of adenomyosis during pregnancy on obstetric outcomes. EVIDENCE SYNTHESIS: Four studies were included for qualitative analysis, we excluded the studies in which adenomyosis was associated to endometriosis. Overall, included studies showed that the patients with adenomyosis have an increased risk of some poor obstetrical outcomes, such as miscarriage, preterm birth, premature rupture of membrane, small gestational age, hypetensive disorders and malpresentation. CONCLUSIONS: The potential consequences of adenomyosis during pregnancy are difficult to evaluate because, now, there are few data available concerning adenomyosis and major obstetrical complications and because the study populations of those studies were small. Our results suggest that women with adenomyosis have needed of a prenatal management in a tertiary center.

Variables Associated with Endometriosis-related Pain: A Pilot Study using a Visual Analogue Scale.

OBJECTIVE: Endometriosis is a complex disease, and pain is an important component of the syndrome. One of the most used methods to assess pain is the visual analogue scale (VAS). The aim of the present research was to study the pain experienced by patients who referred to our unit for endometriosis, using the VAS to understand the variables that could influence it. METHODS: We have conducted a prospective study from February 2012 to December 2016, enrolling 388 patients who referred to a university hospital, in Florence, Italy. We have included in the present study patients during their follow-up for endometriosis; we have also included patients who underwent surgery with a histological diagnosis of endometriosis. We have collected sociodemographic and clinical information regarding age, body mass index (BMI), smoking habit, number of pregnancies, and endometriosis staging. Finally, we have administered the VAS for several symptoms. RESULTS: Dysmenorrhea was the symptom associated with the highest perception of pain (mean VAS score of 5.76). The logistic regression showed that the stage of endometriosis could influence the pain associated to constipation and to dysuria. The linear regression showed that age could influence the pain associated to constipation, to dyspareunia, and to dysmenorrhea. A positive correlation was found between dysmenorrhea and chronic pelvic pain (CPP), between dysmenorrhea and dyspareunia, and between constipation and dysuria. CONCLUSION: Using a validated method, the VAS, we have studied the pain experienced by a group of patients with a history of endometriosis and observed that smoking habit and BMI did not influence the VAS scores, and that dysmenorrhea was associated with the highest perception of pain.

OBJETIVO: A endometriose é uma doença complexa, e a dor é um componente importante da enfermidade. Um dos métodos mais utilizados para avaliar a dor é a escala visual analógica (EVA). O objetivo da presente pesquisa foi estudar a dor sentida pelas pacientes que se referiram à nossa unidade para endometriose, usando a EVA para entender as variáveis que poderiam influenciá-la. MéTODOS: Realizamos um estudo transversal de fevereiro de 2012 a dezembro de 2016, envolvendo 388 pacientes que se referiram a um hospital universitário, em Florença, Itália. Incluímos nossos pacientes do estudo durante o acompanhamento da endometriose; incluímos também pacientes que se submeteram à cirurgia com diagnóstico histológico de endometriose. Coletamos informações sociodemográficas e clínicas sobre idade, índice de massa corporal (IMC), hábito de fumar, número de gravidezes e estágio da endometriose. Finalmente, administramos a EVA para vários sintomas. RESULTADOS: A dismenorreia foi o sintoma associado à maior percepção de dor (média do escore EVA de 5,76). A regressão logística mostrou que o estágio da endometriose poderia influenciar a dor associada à constipação e à disúria. A regressão linear mostrou que a idade poderia influenciar a dor associada à constipação, à dispareunia e à dismenorreia. Uma correlação positiva foi encontrada entre dismenorreia e dor pélvica crônica, entre dismenorreia e dispareunia, e entre constipação e disúria. CONCLUSãO: Utilizando um método validado, a EVA, estudamos a dor sentida por um grupo de pacientes com história de endometriose e observamos que o hábito de fumar e o IMC não influenciaram os escores EVA, e que a dismenorreia foi associada à maior percepção de dor.

Preliminary results of a single-arm pilot study to assess the safety and efficacy of visnadine, prenylflavonoids and bovine colostrum in postmenopausal sexually active women affected by vulvovaginal atrophy.

This single-arm pilot study enrolled 47 post-menopausal women affected by vulvovaginal atrophy (VVA). The Vaginal Health Index Score (VHIS) was evaluated for all women and all completed the Female Sexual Function Index (FSFI) questionnaire at baseline (T0) and after 15 days of vaginal cream treatment with one application per day (T1). Following treatment there was a significant improvement in all VHIS parameters and total score (p < 0.0001). Similarly, there was a significant improvement on four FSFI domains (lubrication, orgasm, satisfaction and pain) and total score (p = 0.001). None of the patients reported any local or systemic side-effects during treatment.

Variables associated with endometriosis-related pain: a pilot study using a visual analogue scale / Variáveis associadas à dor relacionada à endometriose: estudo piloto usando uma escala analógica visual

Abstract Objective Endometriosis is a complex disease, and pain is an important component of the syndrome. One of the most used methods to assess pain is the visual analogue scale (VAS). The aim of the present research was to study the pain experienced by patients who referred to our unit for endometriosis, using the VAS to understand the variables that could influence it. Methods We have conducted a prospective study from February 2012 to December 2016, enrolling 388 patients who referred to a university hospital, in Florence, Italy. We have included in the present study patients during their follow-up for endometriosis; we have also included patients who underwent surgery with a histological diagnosis of endometriosis. We have collected sociodemographic and clinical information regarding age, body mass index (BMI), smoking habit, number of pregnancies, and endometriosis staging. Finally, we have administered the VAS for several symptoms. Results Dysmenorrhea was the symptom associated with the highest perception of pain (mean VAS score of 5.76). The logistic regression showed that the stage of endometriosis could influence the pain associated to constipation and to dysuria. The linear regression showed that age couldinfluencethe pain associated to constipation, to dyspareunia,and to dysmenorrhea. A positive correlation was found between dysmenorrhea and chronic pelvic pain(CPP), between dysmenorrhea and dyspareunia, and between constipation and dysuria. Conclusion Using a validated method, the VAS, we have studied the pain experienced by a group of patients with a history of endometriosis and observed that smoking habit and BMI did not influence the VAS scores, and that dysmenorrhea was associated with the highest perception of pain.

Resumo Objetivo A endometriose é uma doença complexa, e a dor é um componente importante da enfermidade. Um dos métodos mais utilizados para avaliar a dor é a escala visual analógica (EVA). O objetivo da presente pesquisa foi estudar a dor sentida pelas pacientes que se referiram à nossa unidade para endometriose, usando a EVA para entender as variáveis que poderiam influenciá-la. Métodos Realizamos um estudo transversal de fevereiro de 2012 a dezembro de 2016, envolvendo 388 pacientes que se referiram a um hospital universitário, em Florença, Itália. Incluímos nossos pacientes do estudo durante o acompanhamento da endometriose; incluímos também pacientes que sesubmeteramàcirurgia comdiagnóstico histológico de endometriose. Coletamos informações sociodemográficas e clínicas sobre idade, índice de massa corporal (IMC), hábito de fumar, número de gravidezes e estágio da endometriose. Finalmente, administramos a EVA para vários sintomas. Resultados A dismenorreia foi o sintoma associado à maior percepção de dor (média do escore EVA de 5,76). A regressão logística mostrou que o estágio da endometriose poderia influenciar a dor associada à constipação e à disúria. A regressão linear mostrou que a idade poderia influenciar a dor associada à constipação, à dispareunia e à dismenorreia. Uma correlação positiva foi encontrada entre dismenorreia e dor pélvica crônica, entre dismenorreia e dispareunia, e entre constipação e disúria. Conclusão Utilizando um método validado, a EVA, estudamos a dor sentida por um grupo de pacientes com história de endometriose e observamos que o hábito de fumar e o IMC não influenciaram os escores EVA, e que a dismenorreia foi associada à maior percepção de dor.

Composition and roles of intestinal microbiota in children.

OBJECTIVE: To provide an update of the advantages of new-generation molecular diagnostics to study the diversity of intestinal microflora and to evaluate its alteration in human diseases. METHODS: We review recent advances in understanding the complex ecosystem of gut microbiota based on a dynamic and mutual interaction with the host. RESULTS: In vaginal delivery, the contact with the mother's vaginal and intestinal flora is an important source of Lactobacillus, Prevotella and other Bifidobacterium. On the opposite, in cesarean delivery, direct contact of the mouth of the newborn with vaginal and intestinal microbiota is replaced by exogenous non-maternally derived bacteria colonizing the infants' intestine producing a less diverse flora. The original microbiome settings evolve during the growth converging to three main clusters defined "enterotypes" in the adult age. CONCLUSIONS: The key role in human health could depend on the balance between beneficial and harmful microbial species populating the gut, therefore the intestinal microflora can been considered as a potential biomarker and/or therapeutic target in intestinal and extra-intestinal diseases.

Spontaneous heterotopic pregnancy, simultaneous ovarian, and intrauterine: a case report.

Spontaneous heterotopic pregnancy is a rare clinical condition in which intrauterine and extrauterine pregnancies occur at the same time. The occurrence of an ovarian heterotopic pregnancy is a singular event as it comprises only 2.3% of all heterotopic pregnancies, extremely rare among women who conceive naturally. A case of a 28-year old patient was treated for spontaneously conceived heterotopic pregnancy. The patient was admitted to our center with lower abdominal pain and amenorrhoea. A transvaginal ultrasound scan showed an ovarian and an intrauterine heterotopic pregnancy. This was managed laparoscopically. Considering spontaneous pregnancies, every physician treating women of reproductive age should be aware of the possibility of heterotopic pregnancy. It can occur in the absence of any predisposing risk factors; only with an early diagnosis and treatment the intrauterine pregnancies will reach viability with a great chance of a favorable obstetric outcome.