Sexual function after vaginal erbium laser: the results of a large, multicentric, prospective study.

The aim of this multicentric, prospective study was to evaluate the effects of vaginal erbium laser (VEL-SMOOTH®) on sexual function in postmenopausal women suffering from the genitourinary syndrome of menopause (GSM). This study was performed on an outpatient basis without anesthesia or drug use before or after the intervention, using an erbium laser (XS Fotona Smooth®, Fotona, Ljubljana, Slovenia) in 1081 postmenopausal women (age 54.3 ± 3.9 years) treated with up to three laser applications every 30 days. Patients were assessed using the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R). No adverse events were recorded during the study. The FSDS-R scores (n = 554), from basal values of 25.5 ± 3.5, were 11.5 ± 3.0, 10.5 ± 3.5 and 11.5 ± 3.5 at the 4-, 12- and 24-week follow-ups, respectively (p < 0.01 vs. corresponding basal values). Individual FSFI domain scores (n = 569) significantly (p < 0.001) increased after VEL-SMOOTH® treatment and remained significantly higher up to the 24th week after the end of treatment. The total scores, from basal values of 15.5 ± 1.5, were 27.5 ± 2.5, 27.6 ± 2.7and 27.0 ± 3.5 at the 4-, 12- and 24-week follow-ups, respectively (p < 0.01 vs. corresponding basal values). Albeit not randomized, this large, prospective study shows that VEL-SMOOTH® treatment may improve sexual function in postmenopausal women suffering from GSM.

Rationale and design for the Vaginal Erbium Laser Academy Study (VELAS): an international multicenter observational study on genitourinary syndrome of menopause and stress urinary incontinence.

The genitourinary syndrome of menopause (GSM) and stress urinary incontinence (SUI) are common clinical challenges for women's health and quality of life. The laser treatment and particularly the vaginal erbium laser (VEL) may provide a new non-invasive treatment for both GSM and SUI. However, the estimation of the ultimate results of different laser treatments may be altered by different issues, such as patient selection, concomitant treatments, and long-term effect of vaginal laser thermotherapy. In the present paper, we present the protocol for a large multicenter study on the evaluation of the efficacy and safety of VEL for the treatment of GSM and SUI, the Vaginal Erbium Laser Academy Study (VELAS). This study will evaluate the effects of three laser applications in 1500 postmenopausal women. Subjective and objective symptoms will be evaluated prior to the first laser treatment with follow-up visits after 4 weeks from the last laser application, and subsequently after every 3 months for 1 year. Findings from the VELAS have the potential to affect clinical care practice and health decisions for millions of women world-wide for a non-hormonal treatment for GSM and a non-invasive treatment of SUI.

Two dimensional imaging of the virtual source of a supersonic beam: helium at 125 K.

Here we present the first two-dimensional images of the virtual source of a supersonic helium expansion. The images were obtained using a free-standing Fresnel zone plate with an outermost zone width of 50 nm as imaging lens and a beam cooled to around 125 K. The nozzle diameter was 10 µm. The virtual source diameter was found to increase with stagnation pressure from 140 ± 30 µm at po = 21 bar up to 270 ± 25 µm at po = 101 bar. The experimental results are compared to a theoretical model based on the solution of the Boltzmann equation by the method of moments. The quantum mechanical cross sections used in the model have been calculated for the Lennard-Jones (LJ) and the Hurly-Moldover (HM) potentials. By using a scaling of the perpendicular temperature that parametrizes the perpendicular velocity distribution based on a continuum expansion approach, the LJ potential shows a good overall agreement with the experiment. However, at higher pressures the data points lie in between the two theoretical curves and the slope of the trend is more similar to the HM curve. Real gas corrections to enthalpy are considered but they affect the results less than the experimental errors.

Floating offshore wind potential for Mediterranean countries.

Floating offshore wind is a promising renewable energy source for several Mediterranean Countries. The exploitation of this resource will contribute to reducing carbon dependence and support the clean energy transition towards a climate neutral Europe. This work presents a novel methodology for estimating spatially-resolved Levelised Cost of Energy and offshore wind energy potential to provide optimal design of floating offshore wind farms in the Mediterranean Sea. For the first time, each site is optimised based on electrical grid cable design and wind farm layout optimisation using the Jensen wake model. The largest technical capacity potentials are obtained in Libya, Tunisia, Italy and Greece, accounting for 72.2 % of the total Mediterranean potential with a total installed capacity of 782 GW. The average LCOE is 93.4 €/MWh and the average capacity factor is 31.8 %, while 67.5 % of the technical potential has LCOE below 90 €/MWh which demonstrates that floating offshore wind in the Mediterranean could become soon competitive with other renewable energies. Optimal floating wind farm design parameters show the prevalence of a wind farm array of 10x10 wind turbines with a preferred rated power of 15 MW and the HVDC export cable connection. Among the selected floating platforms, Hywind outperforms WindFloat and GICON-SOF in 59.2 % of the suitable areas due to the lower structure material. Policymakers and stakeholders will primarily benefit from this study, which provides them with important information for careful marine spatial planning and the development of floating offshore wind farms in the Mediterranean.

Prominence of Terahertz Acoustic Surface Plasmon Excitation in Gas-Surface Interaction with Metals.

The current understanding of the dynamics of gas-surface interactions is that all of the energy lost in the collision is transferred to vibrations of the target. Electronic excitations were shown to play a marginal role except for cases in which the impinging particles have energies of several electronvolts. Here we show that this picture does not hold for metal surfaces supporting acoustic surface plasmons. Such loss, dressed with a vibronic structure, is shown to make up a prominent energy transfer route down to the terahertz region for Ne atoms scattering off Cu(111) and is expected to dominate for most metals. This mechanism determines, e.g., the drag force acting on telecommunication satellites, which are typically gold-plated to reduce overheating by sunshine. The electronic excitations can be unambiguously discerned from the vibrational ones under mild hyperthermal impact conditions.

Velocity distributions in microskimmer supersonic expansion helium beams: High precision measurements and modeling.

Supersonic molecular beams are used in many applications ranging from spectroscopy and matter wave optics to surface science. The experimental setup typically includes a conically shaped, collimating aperture, the skimmer. It has been reported that microskimmers with diameters below 10 µm produce beams with significantly broader velocity distributions (smaller speed ratios) than larger skimmers. Various explanations for this phenomenon have been proposed, but up till now, only a limited amount of data has been available. Here we present a systematic study of the velocity distribution in microskimmer supersonic expansion helium beams. We compare a 4 µm diameter skimmer with a 390 µm diameter skimmer for room temperature and cooled beams in the pressure range 11-181 bars. Our measurements show that for properly aligned skimmers, the only difference is that the most probable velocity for a given pressure and temperature is slightly lower for a microskimmed beam. We ascribed this to the comparatively narrow and long geometry of the microskimmers which can lead to local pressure variations along the skimmer channel. We compare our measurements to a model for the supersonic expansion and obtain good agreement between the experiments and simulations.

A modified time-of-flight method for precise determination of high speed ratios in molecular beams.

Time-of-flight (TOF) is a standard experimental technique for determining, among others, the speed ratio S (velocity spread) of a molecular beam. The speed ratio is a measure for the monochromaticity of the beam and an accurate determination of S is crucial for various applications, for example, for characterising chromatic aberrations in focussing experiments related to helium microscopy or for precise measurements of surface phonons and surface structures in molecular beam scattering experiments. For both of these applications, it is desirable to have as high a speed ratio as possible. Molecular beam TOF measurements are typically performed by chopping the beam using a rotating chopper with one or more slit openings. The TOF spectra are evaluated using a standard deconvolution method. However, for higher speed ratios, this method is very sensitive to errors related to the determination of the slit width and the beam diameter. The exact sensitivity depends on the beam diameter, the number of slits, the chopper radius, and the chopper rotation frequency. We present a modified method suitable for the evaluation of TOF measurements of high speed ratio beams. The modified method is based on a systematic variation of the chopper convolution parameters so that a set of independent measurements that can be fitted with an appropriate function are obtained. We show that with this modified method, it is possible to reduce the error by typically one order of magnitude compared to the standard method.

Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions.

OBJECTIVE: To present pressure lavage under ultrasound guidance (PLUG) as a new therapeutic procedure for selected cases of intrauterine adhesions (IUA). DESIGN: An open clinical investigation with no control group. SETTING: Teaching hospital. PATIENT(S): Seven consecutive patients referred to our department for secondary amenorrhea due to IUA. INTERVENTION(S): A newly developed technique based on sonohysterography was used to monitor the effects of intrauterine injections of saline solution on the continuous accumulation of saline in the uterine cavity for the mechanical disruption of IUA. MAIN OUTCOME MEASURE(S): Lysis of intrauterine adhesions, restoration of menses, and increased pregnancy rate in infertile patients. RESULT(S): Five patients with mild IUA obtained satisfactory lysis of adhesions by the use of the PLUG technique. A second-look hysteroscopy after 1 month showed that filmy adhesions persisted in two patients with moderate IUA. These adhesions were removed successfully during hysteroscopy. Restoration of menses was obtained and has continued in all patients. Two of the three infertile patients became pregnant. CONCLUSION(S): This technique is safe and ideal as an in-office procedure. PLUG allows complete lysis in mild IUA cases, and the need for therapeutic, and possibly follow-up hysteroscopy, can be avoided. In moderate IUA cases, the procedure may represent a useful initial step in reducing the need for operative hysteroscopy.

A case of acid lipase deficiency: Wolman's disease.

We report a case of Wolman disease, an unusual autosomal recessive disease characterized by storage of lipid in histiocytes. Storage of cholesteryl esters and triglycerides is caused by lysosomal acid lipase deficiency. This enzyme hydrolyses the cholesteryl esters of LDL thus allowing their peripherical metabolism. Onset of the disease occurs after the first month of life with hepatosplenomegaly, diarrhea, vomiting, abdominal distension, failure to thrive. Diagnosis, suspected because of calcifications of the adrenals was achieved by demonstration of lysosomal acid lipase deficiency in lymphocytes and cultured skin fibroblasts. Carriers of the disease can be identified by enzyme assays in lymphocytes and fibroblasts and prenatal diagnosis can be accomplished by lysosomal acid lipase assays in cultured amniotic fluid cells and chorionic villi.

Estroprogestin vs. gonadotrophin agonists plus estroprogestin in the treatment of endometriosis-related pelvic pain: a randomized trial. Gruppo Italiano per lo Studio dell'Endometriosi.

OBJECTIVE: This is a randomized clinical trial comparing estroprogestin (E/P) pill given for 12 months vs. gonadotrophin releasing hormone agonist (GNRHa) given for 4 months followed by E/P pill treatment for 8 months in the relief of endometriosis-related pelvic pain. METHODS: Eligible for the study were women with laparoscopically confirmed endometriosis and pelvic pain lasting 3-12 months after diagnosis. Eligible women were randomly assigned to treatment with E/P pill (gestroden 0.75 mg and ethynlestradiol 0.03 mg) for 12 months (47 patients) vs. tryptorelin 3.75 mg slow release every 28 days for 4 months followed by E/P pill for 8 months (55 patients). RESULTS: At baseline, dysmenorrhea was reported in 46 women allocated to E/P pill only (97.9%), and in all the 55 women allocated to GNRHa+E/P pill. The corresponding value at the 12 months follow-up visit was 14 subjects (35.9%) and 16 subjects (34.8%). The baseline median values of the multidimensional and analog scale were for dysmenorrhea 4 and 6 in the EP only and 3 and 6 in the GNRHa+E/P group. The corresponding value at the 12 months follow-up visit were 2 and 6 and 0 and 5. Non-menstrual pain was reported, respectively, at baseline and 12 month visit by 46 (97.9%) and 15 (38.5%) subjects in the E/P pill group and 49 (89.1%) and 17 (37.0%) of the GNRHa+E/P pill one. The baseline median values of the multidimensional and analog scale were for non-menstrual pain 3 and 5 in the E/P only and 2 and 6 in the GNRHa+E/P group. The corresponding values at the 12 month follow-up visit were 0 and 4 and 0 and 4. These differences between the two groups were not statistically significant. CONCLUSIONS: 1 year after randomization, the two treatment schedules show similar relief of pelvic pain in women with endometriosis.

Massive vulvar edema in ovarian hyperstimulation syndrome. A case report.

BACKGROUND: Bilateral vulvar edema associated with severe ovarian hyperstimulation syndrome is described for the first time. CASE: A 28-year-old woman underwent gonadotropin-releasing hormone analogue and gonadotropin treatment for in vitro fertilization and embryo transfer. On day 18 of the cycle, the patient reported mild abdominal discomfort that became severe during the following four days. One the 22nd day of the cycle, bilateral ovarian enlargement and ascites were present. The vulva showed massive edema and fissures. Ovarian hyperstimulation syndrome (OHSS) therapy consisted of human albumin, lactated Ringer's solution and heparin. The vulvar edema was treated with topical hydrocortisone ointment, ice packs and topical gentamycin twice a day. After one week of treatment, the vulva was normal. CONCLUSION: We think that the vulvar edema in this case was the result of decreased oncotic pressure and increased hydrostatic pressure, as occur during OHSS.

Expanded polytetrafluoroethylene surgical membrane in ovarian surgery on the rabbit. Biocompatibility, adhesion prevention properties and ability to preserve reproductive capacity.

OBJECTIVE: To evaluate the biocompatibility, adhesion prevention properties and ability to preserve reproductive capacity of polytetrafluoroethylene surgical membrane in ovarian surgery on the rabbit. STUDY DESIGN: In two groups of female rabbits a standard lesion was made on each ovary. In group 1, one ovary was partially covered with a flat sheet of the surgical membrane, and the other was left uncovered so that each rabbit served as its own control. In group 2, one ovary was again left uncovered to serve as an internal control, and the other was completely covered with a "cap" of the surgical membrane. Laparotomies were performed several weeks postoperatively after the rabbits were mated with fertile males; adhesions were evaluated, and the number of cornual pregnancies was determined. RESULTS: In group 1, 67.9% of the control ovaries and 7.1% of the partially covered ovaries had adhesions (P < .001); in the uterine horn on the control side, 32.1% of the rabbits exhibited cornual pregnancies (1.14 +/- 1.72 [mean +/- SD] pregnancies per rabbit), whereas on the experimental side, 89.3% of the rabbits exhibited cornual pregnancies (3.89 +/- 1.58 per rabbit). In group 2, 83.3% of the control ovaries and 11.1% of the covered ovaries had adhesions (P < .001); in the uterine horn on the control side, 23.5% of the rabbits exhibited cornual pregnancies (2 +/- 1.1 per rabbit), whereas on the experimental side, 100% of the rabbits exhibited cornual pregnancies (4.8 +/- 0.9 per rabbit). CONCLUSION: The surgical membrane is an excellent device for preventing the formation of adhesions to the ovary after surgery in rabbits, preserving the reproductive capacity of the ovary.

Intraoperative ultrasound guidance for operative hysteroscopy. A prospective study.

OBJECTIVE: To evaluate the efficacy and safety of ultrasound (US) guidance as compared to laparoscopic monitoring during operative hysteroscopy. STUDY DESIGN: Prospective, open study including 81 patients undergoing operative hysteroscopy under US guidance for uterine septum and submucous myoma. Clinical and surgical outcomes were compared with those in an historical control group of 45 patients undergoing the same operation under laparoscopic guidance. RESULTS: US guidance proved satisfactory in all patients, and there were no complications due to insufficient visualization of the pelvic structures; in no case was conversion to laparoscopic guidance required. US scanning was most useful in determining the outer limit of the intramural component of submucous partial intramural myoma, allowing complete resection. During metroplasty, US guidance allowed extension of the resection beyond the normal limit conventionally defined by hysteroscopy; none required reintervention. By comparison, in the control group, a second attempt was required because the operation was insufficiently radical in four patients. CONCLUSION: US guidance was used successfully as the only visual aid for hysteroscopic surgery, comparing favorably with laparoscopy in terms of efficacy and safety.

Vulvar lichen sclerosus. Immunohistologic evaluation before and after therapy.

In 20 women with vulvar lichen sclerosus (LS) we analyzed the immunohistologic features of the dermal lymphoid infiltrate and the number of epidermal CD1a+ cells (Langerhans cells). Activated (HLA-Dr+) T cells, associated with CD1a+ accessory cells, were found in the dermis in all cases. The number of CD1a+ epidermal cells was increased, and the cells expressed strong HLA-DR+ staining. These findings suggest activation of the skin immune system in vulvar LS lesions. Conventional 2% testosterone therapy failed to modify the immunohistologic features. Clobetasol, 0.05%, application seemed more effective in down-regulating the skin's immune system activation profile.

True incidence of vaginal vault prolapse. Thirteen years of experience.

OBJECTIVE: To assess the true incidence of vaginal vault prolapse after hysterectomy. STUDY DESIGN: The records of 2,670 patients who had undergone hysterectomy between 1983 and 1987 were reviewed. From this population, 448 patients were selected for follow-up study. The mean follow-up phase was 11 years (range, 9-13). Patients were divided into two groups according to the presence or the absence of genital prolapse at hysterectomy. Pelvic examination was performed in order to identify the presence of vault prolapse. Pelvic support was assessed using Baden and Walker's "halfway description." RESULTS: Five of the 2,670 patients who had undergone hysterectomy at our institution returned on their own initiative for surgical correction of vault prolapse. Using the modalities in the literature, the incidence of vault prolapse was 0.4%. Instead, on pelvic examination, the incidence of vault prolapse was 4.4% (20 patients in a group of 448). Fourteen of the 20 with vault prolapse had previously undergone vaginal hysterectomy for genital prolapse: six had had abdominal hysterectomy for benign disease, excluding genital prolapse. Therefore, the incidence of vaginal vault prolapse was 11.6% (14/120 patients) when hysterectomy had been performed for genital prolapse and 1.8% (6/328) when hysterectomy had been performed for other benign diseases. In the latter group (328 patients), all the cases of vault prolapse developed after abdominal hysterectomy: the incidence was 2% (6/308 patients); no case (0/20 patients) of vault prolapse developed after vaginal hysterectomy that had been performed on patients without genital prolapse. The primary risk factor for vaginal vault prolapse in this study, was obesity. Obese subjects were significantly more susceptible to developing the condition when compared to nonobese (P < .001). CONCLUSION: Our data show that there is a low incidence of vaginal vault prolapse when hysterectomy is performed in the absence of defects in pelvic support. A comparison of our method and those described in the literature to determine the incidence of vaginal vault prolapse showed that this event is often underevaluated if long-term follow-up after hysterectomy is not carried out.

Lichen sclerosus and squamous hyperplasia of the vulva. A clinical study of medical treatment.

One hundred thirty-eight cases of nonneoplastic epithelial disorders of the vulva treated with medical therapy from 1984 to 1988 were evaluated at the University of Florence, Florence, Italy. The 67 cases of lichen sclerosus were treated with testosterone propionate or progesterone ointment for 32 weeks. The 31 cases of squamous hyperplasia were treated with corticosteroid ointment for 16 weeks. The 40 patients with lichen sclerosus associated with squamous hyperplasia were treated with corticosteroid ointment for 12 weeks and then with testosterone propionate ointment for another 20. To evaluate the efficacy of the treatments, the patients were examined before and after therapy. The evaluation took into account the symptoms and gross appearance of the lesions, which were given a score of 1-3. Considering all the cases evaluated, a total regression of symptoms occurred in 82 patients (59.4%), while a partial regression occurred in 37 (26.8%). Furthermore, there was a total regression of gross changes in 68 cases (49.3%) and a partial one in 43 (31.1%). The best results were obtained with squamous hyperplasia, which lichen sclerosus, alone or associated with squamous hyperplasia, yielded less successful results.

Clinical and histologic effects of topical treatments of vulval lichen sclerosus. A critical evaluation.

A randomized study was conducted on 79 patients with vulval lichen sclerosus who were treated for three months with four topical drugs including testosterone (2%), progesterone (2%), clobetasol propionate (.05%) and a cream based preparation. To evaluate the efficacy of the treatments, patients were examined before and after therapy for symptoms, gross appearance of the lesions and histopathologic features. Patients treated with clobetasol had a better response than responses recorded in the other groups. Remission of symptoms occurred in 75% of patients treated with clobetasol compared to 20% treated with testosterone, 10% treated with progesterone and 10% treated with a cream based preparation. The clobetasol group was the only group with gross changes and histologic evaluations before and after treatment, that showed a highly significant difference (P < .001). In a condition characterized by epidermal atrophy, we observed a significant reduction in epidermal atrophy after treatment. This study suggests that clobetasol propionate (.05%) (a very potent topical steroid) is the therapy of choice in vulval lichen sclerosus.

Testosterone maintenance therapy. Effects on vulvar lichen sclerosus treated with clobetasol propionate.

OBJECTIVE: To evaluate the possible effects of topical testosterone as maintenance therapy after clobetasol propionate treatment. STUDY DESIGN: Thirty-two patients with biopsy-proven vulvar lichen sclerosus (LS), after 24 weeks of treatment with 0.05% clobetasol propionate cream, were randomly distributed into two groups of 16 each and treated for a further length of time (24 weeks) with testosterone 2% ointment or a cream-based preparation (placebo). The patients were examined before and after treatment for symptoms, gross aspects and histologic features. RESULTS: With clobetasol propionate all patients had a marked improvement (P < .001) in both clinical and histologic parameters. After clobetasol propionate therapy, the 16 testosterone-treated patients had significant worsening of their symptoms (P < .05%) and no evident changes in gross aspects (P = NS). The placebo-treated group had good symptomatic control of their disease, with no significant changes in symptoms or gross aspects (P = NS). CONCLUSION: After the good results obtained with clobetasol propionate, treatment with testosterone appeared to have a negative effect, while a regularly provided emollient cream was useful in symptom control.

[Surgical stress and anesthetic protection]. / Stress chirurgico e protezione anestesiologica.

Surgical pain triggers a series of neuro-endocrine change in the patient's organism both during the operation and at the post-operative stage, exposing the patient to a parapathological and quite afinalistic situation. It is the task of anaesthesia to prevent these adaptation reactions setting in or at least to attenuate them. Various anaesthesiological techniques are compared and results are examined with a view to establishing what technique is capable of procuring most anaesthesiological "protection".