Racial and ethnic disparities in non-invasive prenatal testing adherence: a retrospective cohort study.

BACKGROUND: Fetal aneuploidies, including trisomies 21, 13, and 18, represent a significant issue in prenatal care. The advent of non-invasive prenatal testing (NIPT) through the detection of cell-free DNA (cf-DNA) in maternal blood has modified screening for chromosomal abnormalities. This study evaluates NIPT adherence among pregnant of different ethnicities, addressing potential disparities in prenatal care. METHODS: This was a retrospective, single-center study conducted at a tertiary care university hospital in Italy between March 31, 2021, and September 30, 2022. Participants were categorized by ethnicity (Asian/Pacific islander, Black, Latina, White, Middle Eastern). Maternal demographic characteristics and prenatal test data were recorded. Comparative analyses were executed utilizing a One-Way Analysis of Variance (ANOVA) Test, augmented by Tukey's honestly significant difference test for post-hoc evaluation. Statistical significance was denoted by a P value (P)<0.05. A multivariate analysis through a multinomial regression model was conducted for the results to detect potential bias. RESULTS: Six hundred seventeen pregnancies were included: 418 White, 105 Asian/Pacific islander, 46 Black, 40 Latina, and 8 Middle Eastern. Maternal age showed no significant variation. Black ethnicity had higher prepregnancy Body Mass Index (BMI; mean: 27.5 kg/m2±SD: 5.92, P=0.02), while Asian and White pregnancies had higher nulliparity rates (63.8% and 70.8%). Black ethnicity had no NIPT uptake (0.00%). Asian/Pacific islander and Latina pregnant had lower NIPT utilization (9.5% and 7.5%, P<0.001). White ethnicity had a higher NIPT rate (27.5%). In the NIPT group, 8.9% of White and 12.5% of Middle Eastern pregnancies chose cf-DNA without a prior first-trimester ultrasound test. Considering the first-trimester screening, 30.4% of Black pregnancies had nuchal translucency, while 17.4% combined it with beta-human chorionic gonadotrophin (ß-hCG) and associated plasma protein-A (PAPP-A; P<0.001). White pregnancies had high adherence: 74.6% had nuchal translucency and 53.8% had a first-trimester combined test. Overall, 69.6% of Black pregnancies skipped both tests versus 16.5% in the White group (P<0.001). CONCLUSIONS: Significant disparities in prenatal care and NIPT adherence were observed among pregnant women of diverse ethnic backgrounds. Lower cf-DNA adhesion and limited adherence to first-trimester screening were observed among any ethnicities. These findings highlight the critical need for targeted interventions and policies to reduce barriers and facilitate access to prenatal care for all women.

Reproductive outcome after cesarean scar pregnancy.

Cesarean scar pregnancy (CSP) rate is rising worldwide, in parallel with the rising rates of cesarean delivery. Multiple therapeutic strategies and a timely diagnosis have led to a successful management in most cases, with many women preserving fertility after treatment. Despite this, still little is known regarding pregnancy outcomes after a CSP. The main adverse outcomes reported after CSP are recurrence of CSP, miscarriage, preterm birth, placenta accreta spectrum (PAS) disorders and uterine rupture. In addition, little is known about the influence of the different treatments on subsequent pregnancy outcomes after a CSP. Being aware of the impact of the different management strategies on the fertility outcomes is highly relevant to counsel pregnant women after a CSP. The aim of this manuscript is to provide an up-to-date review of the reproductive outcomes of women with a history of CSP and of the influence of various treatments on subsequent pregnancy outcomes.

Universal third-trimester obstetrical ultrasonography: a cross-sectional analysis of a national survey.

BACKGROUND: Universal third-trimester obstetrical ultrasonography represents a medical debate. The current survey was conducted to evaluate the actual use of third-trimester scan and understand gynecologists' aptitude. METHODS: A survey was mailed to 128 gynecologists between January and February 2020. Data about their demographic's characteristics, hospital ward, and self-assessment questionnaires were recorded. Results were evaluated by using combined analysis. RESULTS: Overall, 128 (29.8%) gynecologists answered. Their age ranged between 45 and 64 years (70.3% of the total, 90/128). The half part worked in hospitals and university hospitals (39.8%, 51/128 and 10.1%, 13/128, respectively), 26.5% (34/128) worked in private hospitals and 23.4% (30/128) in public ambulatories. The neonatal intensive care unit was present in 37.5% (48/128) of the cases. 96.0% of gynecologists surveyed (123/128) offered the universal third-trimester scan (28-32 weeks) and 78.1% of the physician recommended the universal 35-37 weeks ultrasonographical exam. A subanalysis among third level hospital gynecologists versus gynecologists without neonatal intensive care unit showed no statistical difference. CONCLUSIONS: This survey reveals extensive use of third-trimester scan in low-risk pregnancy. Nevertheless, randomized controlled trials concerning the universal third-trimester scan are required to validate this clinical attitude.

Is Uterine Myomectomy a Real Contraindication to Vaginal Delivery? Results from a Prospective Study.

OBJECTIVES: The main goal of our research was to explore correlations between a history of uterine myomectomy and maternal-fetal outcomes, throughout a comparison between vaginal deliveries in patients with or without a history of uterine myoma excision. MATERIALS AND METHODS: A prospective study was carried out at two tertiary care hospitals between January 2019 and January 2020. Women were assigned into two groups according to the history of laparoscopic or laparotomic myomectomy (Group 1) or without myomectomy (Group 2). RESULTS: 80 women successfully delivered after myomectomy. Pregnancies with previous laparoscopic or laparotomic myomectomy were associated with a minor rate of spontaneous labor onset (RR 1.17; 95% CI 1.04 - 1.31) and with an increased rate of emergency cesarean section (RR 1.22; 95% CI 1.09 - 1.36). Moreover, myomectomy group had a significant number of indications to emergency cesarean section correlated to suspected uterine rupture (RR 1.19; 95% CI 1.02-1.39). There were no uterine ruptures or neonatal deaths recorded. First stage of labor was longer in the myomectomy group (316 vs 204 mins, p = 0.01). No differences in the rates of the prolonged first and second stage of labor, postpartum hemorrhage and vaginal laceration, and no neonatal adverse outcomes were found between groups. CONCLUSIONS: Pregnancies after myomectomy might be associated with an elevated rate of emergency cesarean section only due to a higher percentage of suspected uterine rupture, without a real hazard of adverse obstetric or neonatal outcomes.

Impact of Braxton-Hicks contractions on fetal wellbeing; a prospective analysis through computerised cardiotocography.

To estimate the correlation between the maternal perception of Braxton-Hicks contractions (BHC) and foetal wellbeing throughout antepartum computerised cardiotocography (cCTG) parameters, we performed a prospective observational study between April 2019 and March 2020. Non-labouring women with a term pregnancy were recruited. We collected data regarding maternal perception of BHC in the last two weeks before delivery. For each patient, an external computerised cardiotocography (cCTG) was registered. Women were subdivided in accordance with perception or non-perception of BHC. Fifty women were recruited. Women who felt BHC showed higher foetal heart rate (135 bpm vs 128 bpm, p = .008), lower long-term variability (47.2 ms vs 57.7 ms, p = .02) and reduced number of accelerations (7.8 vs 11.4, p = .04). In conclusion, the absence of mother's perception of BHC showed lower baseline foetal heart rate, increased number of accelerations and higher long-term variability related to mothers who perceived BHC.IMPACT STATEMENTWhat is already known on this subject? BHC are common painful contractions that start in the third trimester. They are random spots of uterine action that happen in the absence of sufficient gap-junction connectivity. BHC have a significant impact on foetal wellbeing.What do the results of this study add? BHC are associated with reduced long-term variability during cCTG examination. Moreover, baseline foetal heart rate seems lower, and accelerations are less frequent when BHC are felt by pregnant women.What are the implications of these findings for clinical practice and/or further research? These findings could be related to a cumulative effect on the uterine flow mediated by BHC. Further researches are needed to state the impact of BHC on the foetal wellbeing.

Maternal and Fetal Outcomes in Women with Diabetes in Pregnancy Treated before and after the Introduction of a Standardized Multidisciplinary Management Protocol.

BACKGROUND: Diabetes in pregnancy is associated with an increased risk to the woman and to the developing fetus. Currently, there is no consensus on the optimal management strategies for the follow-up and the timing of delivery of pregnancies affected by gestational and pregestational diabetes, with different international guidelines suggesting different management options. MATERIALS AND METHODS: We conducted a retrospective cohort study from January 2017 to January 2021, to compare maternal and neonatal outcomes of pregnancies complicated by gestational and pregestational diabetes, followed-up and delivered in a third level referral center before and after the introduction of a standardized multidisciplinary management protocol including diagnostic, screening, and management criteria. RESULTS: Of the 131 women included, 55 were managed before the introduction of the multidisciplinary management protocol and included in group 1 (preprotocol), while 76 were managed according to the newly introduced multidisciplinary protocol and included in group 2 (after protocol). We observed an increase in the rates of vaginal delivery, rising from 32.7% to 64.5% (<0.001), and the rate of successful induction of labor improved from 28.6% to 86.2% (P < 0.001). No differences were found in neonatal outcomes, and the only significant difference was demonstrated for the rates of fetal macrosomia (20% versus 5.3%, P: 0.012). Therefore, the improvements observed in the maternal outcomes did not impact negatively on fetal and neonatal outcomes. CONCLUSION: The introduction of a standardized multidisciplinary management protocol led to an improvement in the rates of vaginal delivery and in the rate of successful induction of labor in our center. A strong cooperation between obstetricians, diabetologists, and neonatologists is crucial to obtain a successful outcome in women with diabetes in pregnancy.

Performance of cell-free DNA sequencing-based non-invasive prenatal testing: experience on 36,456 singleton and multiple pregnancies.

BACKGROUND: This paper describes the clinical practice and performance of cell-free DNA sequencing-based non-invasive prenatal testing (NIPT) as a screening method for fetal trisomy 21, 18, and 13 (T21, T18, and T13) and sex chromosome aneuploidies (SCA) in a general Italian pregnancy population. METHODS: The AMES-accredited laboratory offers NIPT in maternal blood as a screening test for fetal T21, T18, T13 and SCA. Samples were sequenced on a NextSeq 550 (Illumina) using the VeriSeq NIPT Solution v1 assay. RESULTS: A retrospective analysis was performed on 36,456 consecutive maternal blood samples, including 35,650 singleton pregnancies, 800 twin pregnancies, and 6 triplet pregnancies. Samples were tested between April 2017 and September 2019. The cohort included 46% elevated-risk and 54% low-risk patients. A result indicative of a classic trisomy was found in 356 (1%) of singleton or twin samples: 254 T21, 69 T18, and 33 T13. In addition, 145 results (0.4%) were indicative of a SCA. Of the combined 501 screen-positive cases, 484 had confirmatory diagnostic testing. NIPT results were confirmed in 99.2% (247/249) of T21 cases, 91.2% (62/68) of T18 cases, 84.4% (27/32) of T13 cases, and 86.7% (117/135) of SCA cases. In the 35,955 cases reported as unaffected by a classic trisomy or SCA, no false negative cases were reported. Assuming that false negative results would be reported, the sensitivity of NIPT was 100.00% for T21 (95% Cl 98.47-100.0), T18 (95% Cl 94.17-100.0), and T13 (95% Cl 87.54-100.0). The specificities were 99.99% (95% Cl 99.98-100.0), 99.98% (95% Cl 99.96-100.0), 99.99% (95% Cl 99.97-100.0), and 99.95% (95% Cl 99.92-99.97) for T21, T18, T13, and SCA, respectively. CONCLUSION: This retrospective analysis of a large cohort of consecutive patients who had whole-genome sequencing-based NIPT for classic trisomies and SCA shows excellent detection rates and low false positive rates.

Non-hormonal Treatments For Menopausal Symptoms and Sleep Disturbances: A Comparison Between Purified Pollen Extracts and Soy Isoflavones.

BACKGROUND: Besides hot-flushes, sleep disturbances increase around menopause, impacting on the quality of life. When hormone replacement therapy is contraindicated, it is necessary to provide alternative treatments. OBJECTIVES: This study aimed to observe the effects of an herbal remedy from pollen extracts and soy isoflavones for menopausal complaints, particularly on sleep disorders. METHODS: A six-month prospective observational study was performed in women in natural menopause suffering from menopausal symptoms and sleep disturbances. Three groups were compared: 57 women receiving two tablets/ day containing herbal remedy from pollen extracts (group A), 60 women receiving one tablet/day containing isoflavones 60 mg (group B), 47 women not receiving any treatment (group C). At 3 (T3) and 6 months (T6), the daily number of hot-flushes, Kupperman index for menopausal symptoms, the Pittsburgh Sleep Quality Index (PSQI) test were assessed. RESULTS: Both groups A and B showed a significant improvement of hot flushes (p<0.001) and Kuppermann Index (p<0.001) from T0 to T3 and from T0 to T6. No significant differences between treatment groups were found at T3, while at T6 group A showed greater decrease of daily hot flashes and better improvement of Kupperman Index as compared to group B (respectively, -48.8% versus -18.4% and -24.4% versus -15.4%; p<0.001). Improvement of global sleep quality was more evident in the pollen treated group compared to isoflavones group at both three (-24.7% versus -9.3%, p<0.001) and six (-52.9% vs -4.0%; p<0.001) months, mainly for the scores related to subjective sleep quality, sleep latency and habitual sleep efficiency. CONCLUSION: Non-hormonal treatments can effectively be used in symptomatic menopausal women: among these, after six months of treatment, pollen extracts might achieve a better improvement of hot flushes, sleep disturbances and menopause-related symptoms than soy isoflavones. Herbal remedy from pollen extracts is mainly effective when the quality of sleep is the most disturbing complaint.

A Nutraceutical Approach to Menopausal Complaints.

The menopausal transition, or perimenopause, is characterized by menstrual irregularities, vasomotor symptoms, sleep disturbances, mood symptoms, and urogenital tract atrophy. These changes can also affect the quality of life and one's self-esteem. Hormone replacement therapy (HRT) is considered the best option to achieve therapeutic relief of different menopausal symptoms but is usually restricted to moderate or severe symptoms. Moreover, many women refuse HRT for a variety of reasons concerning the fear of cancer and other adverse effects. According to these considerations, new topics are emerging: Dissatisfaction with drug costs and conventional healthcare, desire for personalized medicines, and the public perception that "natural is good". In this context, nonhormonal therapies are mostly evolving, and it is not unusual that women often request a "natural" approach for their symptoms. The aim of this study is to investigate nonhormonal therapies that have been identified to reduce the menopausal symptoms.

Genetic Contribution in Low Back Pain: A Prospective Genetic Association Study.

OBJECTIVES: Chronic pain is one of the most common reasons individuals seek medical attention. It is a major issue because of the wide interindividual variability in the analgesic response. This might be partly explained by the presence of variants in genes encoding molecules involved in pharmacodynamics and pharmacokinetics. The aim was to analyze opioid effectiveness in chronic low back pain (CLBP) relief after opioid titration, unveiling the impact of pharmacogenetics. METHODS: The study included 231 opioid-naïve patients from the Spine Unit; age 63 ± 14 years, 64% female, body mass index 29 ± 6 kg/m2 , visual analog scale pain intensity score 73 ± 16 mm. Clinical data were collected at baseline, 3 months after opioid titration, and after 2 to 4 years of follow-up concerning pain (intensity and relief), quality of life, disability, comorbidities, and drug prescription (opioid dose, rotations, and adverse events). The genotype influence of OPRM1, COMT, UGT2B7, ABCB1, KCNJ6, and CYP3A5*3A in analgesic response was analyzed by reverse-transcription polymerase chain reaction genotyping. RESULTS: Patients with the COMT G472A-AA genotype (rs4680) and KCNJ6 A1032G-A allele (rs2070995) CLBP responded differently to opioid titration, with higher pain intensity requiring higher dosing. Furthermore, GG- genotypes of A118G (OPRM1, rs1799971) and A854G (UGT2B7, rs776746) influenced the neuropathic component. After opioid titration, CLBP intensity, neuropathic component, low back pain disability, anxiety, and depression significantly decreased, while quality of life improved. CONCLUSION: Single-nucleotide polymorphisms in genes involved in pain transmission and opioid metabolism might predispose to exaggerated sensitivity and differences in the opioid analgesic effect in patients with CLBP. We encourage clinical trials for their clinical application in chronic pain management.

The evolution of compost stability and maturity during the full-scale treatment of the organic fraction of municipal solid waste.

Composting is the method most commonly applied worldwide for the recovery of the source sorted organic waste. The process aims at stabilizing the organic matter, so as to produce a material with soil improver properties, referred to as compost. The effective recovery of the organic waste fraction via composting implies compost safe use on soil. In this view, the assessment of compost characteristics, depending on both the quality of the input material and the process operation, is fundamental. At full scale, the process monitoring usually relies on parameters enabling the indirect control of its evolution, whereas the biological stability and maturity are usually evaluated on the final product. Aim of this work was in assessing both biological stability and maturity during the composting process of the organic fraction of municipal solid waste performed at industrial scale. Representative samples were collected over time in a composting facility operating in the South of Italy and analysed by the dynamic respirometric index, the content of humic substances as well as by their phytotoxicity. Results showed the key role of stability and maturity parameters in the monitoring of composting processes. Experimental outcomes further addressed wider considerations on the operational procedures for a sustainable compost production process.

ß2­adrenergic receptor functionality and genotype in two different models of chronic inflammatory disease: Liver cirrhosis and osteoarthritis.

The present study was designed to investigate the functional status of ß2 adrenoceptors (ß2AR) in two models of chronic inflammatory disease: liver cirrhosis (LC) and osteoarthritis (OA). The ß2AR gene contains three single nucleotide polymorphisms at amino acid positions 16, 27 and 164. The aim of the present study was to investigate the potential influence of lymphocyte ß2AR receptor functionality and genotype in LC and OA patients. Blood samples from cirrhotic patients (n=52, hepatic venous pressure gradient 13±4 mmHg, CHILD 7±2 and MELD 11±4 scores), OA patients (n=30, 84% Kellgren­Lawrence severity 4 grade, 14% knee replacement joint) and healthy volunteers as control group (n=26) were analyzed. Peripheral blood mononuclear cells (PBMC) were isolated from whole blood and basal and isoproterenol induced adenylate cyclase activity (isoproterenol stimulus from 10­9 to 10­4 mM), and ß2AR allelic variants (rs1042713, rs1042714, rs1800888) were determined. ß2AR functionality was decreased in the two different models of chronic inflammatory disease studied, OA (50% vs. control) and LC (85% vs. control). In these patients, the strength of the ß2AR response to adrenergic stimulation was very limited. Adrenergic modulation of PBMC function through the ß2AR stimulus is decreased in chronic inflammatory processes including LC and OA, suggesting that the adrenergic system may be important in the development of these processes.

G protein-coupled receptor signalling potentiates the osmo-mechanical activation of TRPC5 channels.

TRPC5 is an ion channel permeable to monovalent and divalent cations that is widely expressed in different tissues. Although implicated in the control of neurite extension and in the growth cone morphology of hippocampal neurons, as well as in fear-related behaviour, the mechanisms by which TRPC5 is activated remain poorly understood. TRPC5 is known to be activated downstream of Gq-coupled receptors and by membrane stretch, and since there is evidence that mechanical stress may directly activate Gq-coupled receptors, we examined the relationship between the activation of TRPC5 by the type 1 histamine receptor and osmotic stress. Using calcium imaging and patch clamp recordings, we found that a higher proportion of cells expressing TRPC5 respond to hypoosmotic solution when they co-express H1R. This response is associated with a phospholipase C-dependent increase in the cells internal calcium concentration, which is abolished on depletion of calcium stores. We also found that the hypoosmotic stimulus that provokes mechanical stress drives the translocation of TRPC5 to the plasma membrane by a mechanism dependent on PI3K. This increase in TRPC5 at the plasma membrane augments the proportion of cells that respond to hypoosmotic stimulation. Together, these results suggest that hypoosmotic cell-swelling activates Gq-coupled receptors, which in turn enhance the activation of TRPC5 by regulating this channel membrane trafficking. Gq-coupled receptors and TPRC5 are co-expressed in several tissues such as those of the vascular system and in somatosensory neurons, suggesting that this mechanism of TRPC5 activation may have interesting and important implications in arterial pressure sensing and mechanotransduction.

Assessment of guidelines to improve diagnosis and treatment of solid pseudopapillary tumor of the pancreas. A case report and literature review.

AIM: Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm, its preoperative diagnosis is difficult and therefore inappropriate therapy or postoperative complications are frequent. Reviewing the literature, the purpose of this article was to identify guidelines to improve diagnosis and treatment of SPT. CASE REPORT: Authors report a case of SPT of the pancreas in a 27-year-old woman in whom a mistaken radiologic diagnosis made surgical strategy difficult and caused postoperative complications. DISCUSSION/CONCLUSIONS: Clinicians and surgeons should: (1) consider the possible disease of SPT in young females, with pancreatic encapsulated lesion with well-defined borders and variable central areas of cystic degeneration, necrosis or hemorrhage showed on radiological examinations. (2) Intensity of the differentiation of the clinical symptoms, especially during the course of therapy of chronic gastritis and diabetes. (3) Use immunohistochemical stains of alpha-1-antitrypsin, alpha-1-antichymotrypsin, vimentin and neuron-specific enolase. (4) Keep this unusual but potentially curable tumor in mind, following patients who had suffered from acute pancreatitis or abdominal injury. Increasing experience with this tumor leads to a greater awareness of its clinical presentation and pathological features and a lower rate of misdiagnosis. (5) Finally, perform, where technically feasible, conservative surgical treatment, that is safe and effective.

[Surgical treatment of extraperitoneal rectal cancer]. / Trattamento chirurgico del carcinoma del retto extraperitoneale. Chirurgia "open" con conservazione sfinterica, TME nerve-sparing, fast-track, senza stomia di protezione.

The aim of the study was to evaluate the results of open surgery with sphincter preservation and nerve-sparing total mesorectal excision and a fast-track protocol, without a protective stoma in a consecutive series of patients with extraperitoneal rectal cancer. From 1998 to 2007, 89 patients with extraperitoneal rectal cancer were treated according to a prospective protocol. Eight-six patients were submitted to anterior resection with a low or ultra-low anastomosis and nerve-sparing total mesorectal excision. Fifty-four patients received neoadjuvant therapy. Twenty-eight patients were treated according to a fast-track postoperative protocol. Primary protective colostomies were performed in 6 cases (6.9%), while a secondary colostomy was necessary in 3 patients (3.4%). There was just one postoperative death (1.1%) and major morbidity occurred in 12.3%. Seven patients developed anastomotic dehiscence; 3 were successfully treated with a secondary colostomy and 4 were treated conservatively. 68.4% of the patients treated with the fast-track protocol could be discharged on postoperative day 4. 73% of patients were still surviving at a 5-year follow-up (48 patients). The incidence of local recurrences was 3.1%. Anterior resection in the form of open nerve-sparing total mesorectal excision with selective use of neoadjuvant therapy can be successfully performed without a protective stoma in more than 80% of patients. The fast-track protocol seems to increase the quality of the patient's postoperative condition and reduce the hospital stay.

Protective stoma in anterior resection of the rectum: when, how and why?

BACKGROUND: The use of protective stoma in anterior resection (AR) is controversial. Neoadjuvant therapy, TME and laparoscopy seem to increase the rate of anastomotic dehiscences (a.d.). PATIENTS AND METHODS: In a prospective study, 219 patients were submitted to elective open AR (109 patients), open AR+TME nerve-sparing (110 patients), 35 of which had intrasphinteric anastomosis. Fifty-five patients were treated by neoadjuvant therapy. Primary stoma was not performed. RESULTS: We had 15 (6.8%) a.d.: 5 (2.3%) major and 10 (4.4%) minor. In the five major a.d. an immediate colostomy was performed with one death. In the 10 minor the a.d. was cured conservatively. CONCLUSIONS: A protective stoma is necessary in less than 10% of the patients treated with AR, so avoiding further surgery, mortality, morbidity and higher medical costs in most patients.

Neurectomy to prevent persistent pain after inguinal herniorraphy: a prospective study using objective criteria to assess pain.

BACKGROUND: Although tension-free mesh repair has markedly improved the outcome of inguinal hernia surgery, it has only minimally reduced the incidence of persistent postoperative pain. The pathogenesis of this complication and treatment remain unclear. STUDY DESIGN: In order to objectively assess whether iliohypogastric neurectomy reduces the incidence and intensity of persistent postoperative pain, we prospectively studied 100 male patients with bilateral inguinal hernia who underwent tension-free surgical repair, combined with iliohypogastric neurectomy on the right side alone. Pain was evaluated postoperatively on days 1 and 7 and at 1 and 2 years by means of a visual analog scale. Patients were given a questionnaire including coded terms for describing pain. These terms were designed to compare pain on the neurectomized and non-neurectomized sides and assess altered sensation (hypoesthesia and paresthesia) on both sides. RESULTS: There were differences in the incidence and intensity of pain between the neurectomized and non-neurectomized sides, though these differences were not significant. Individual patient assessment showed that from postoperative day 7 onward patients had on average less pain on the neurectomized side. Pain reduction was more prominent in patients who scored 4 or more on the visual analog scale. No significant difference was found in the incidence of sensory alterations between the two sides. Two years after inguinal hernia repair, only one of the 100 patients studied still had persistent pain (>4 on the visual analog scale); this pain was on the non-neurectomized side. CONCLUSIONS: Our prospective data do not reach statistical significance to claim that iliohypogastric neurectomy reduces the incidence and intensity of persistent postoperative pain after tension-free inguinal hernioplasty. Studies on larger patient samples are warranted to provide definitive, statistically supported conclusions.

Axillary metastasis as first symptom of occult breast cancer: a case report.

Axillary lymph node metastasis from an occult breast carcinoma is a rare occurrence. We report this condition in a 59-year-old woman who presented with a swelling in the right axilla. No breast mass was clinically evident. Mammography, ultrasonography and multiple random fine-needle breast biopsies yielded no pathological findings. No extramammary primary lesions were present. Axillary sampling was performed and histological examination revealed the presence of metastatic adenocarcinoma in three of the 12 dissected lymph nodes. Estrogen receptors were positive and immunohistochemistry pointed to a breast origin. All these data were suggestive of occult breast cancer. The patient refused any further treatment but accepted clinical and radiological follow-up. Eight years later mammography revealed in the same breast a 10-mm nodule containing microcalcifications, which was not evident at physical examination. The patient underwent a lumpectomy. Intraoperative histology was positive for breast carcinoma and complete axillary clearance was performed. Histological examination revealed a lobular invasive breast carcinoma and the presence of micrometastasis in one of the 23 removed lymph nodes. The patient was given radiotherapy to the breast and axilla and tamoxifen. At present, one year after the appearance of the primary tumor, she is free of disease. Based on this case report we suggest an eclectic approach in the management of patients with axillary metastasis from occult breast cancer, depending on the clinical, pathological and biological findings.