Reducing vaccine hesitancy in pregnancy by the health literacy model inclusive of modern communication tools.

Albeit the vaccination is one of the most successful and cost-effective public health interventions, reluctance or refusal to vaccinate represents one of the ten threats to global health by the World Health Organization. Additional efforts to promote vaccination are required for at higher risk categories, such as pregnant women. Our approach supports the role of a clear and transparent communication by using efficient interventions and educational strategies to increase both willingness and confidence for preventable diseases in neonates and infants by vaccinations in pregnancy.

Assessment of post-partum haemorrhage risk among women with moderate thrombocytopenia.

It is unknown whether moderate thrombocytopenia represents a risk factor for post-partum haemorrhage (PPH). We assessed PPH risk among women with a platelet count of between 100 and 50 × 109 /l and stratified the risk for O/non-O blood group. We included consecutive women undergoing vaginal delivery or caesarean section with moderate thrombocytopenia. Women with >150 × 109 /l platelets at delivery were selected as controls and matched for age, type of birth and ethnicity. Odds ratios (ORs) with their 95% confidence intervals (95% CIs) were calculated as risk estimates. A total of 94 thrombocytopenic women and 94 controls were included in the study. The rate of PPH was significantly higher in thrombocytopenic women than in controls (37% vs. 10%, p < 0.001); there was a higher risk of PPH in the thrombocytopenic group when compared to the control group (adjusted OR 4.7, 95% CI 2.1-10.8, p < 0.01) and this association was stronger in blood group O carriers (adjusted OR 11.0, 95% CI 2.4-49.6, p < 0.01). In conclusion, our study shows that a moderate thrombocytopenia is a risk factor for PPH, especially in blood group O carriers.

Hyperandrogenism and menstrual imbalance are the best predictors of metformin response in PCOS patients.

BACKGROUND: Moving from the correlation between insulin-resistance and PCOS, metformin has been administered in some PCOS women improving ovulatory and metabolic functions and decreasing androgen levels. Inconsistency and unpredictability of response to metformin limit its extensive use. Aim of this study was to identify reliable predictors of response to metformin therapy for weight loss and reduction in plasma androgen levels using ANNs (artificial neural networks). METHODS: One hundred eight consecutive women with PCOS (ESHRE/ASRM 2003 Rotterdam criteria) treated with metformin 1500 mg/day, at inclusion and every 6 months underwent to a complete clinical, endocrine/metabolic assessment and ultrasonographic evaluation. Therapy outcomes were BMI reduction (≥1 kg/m2) in overweight/obese and free-androgen-index (FAI) decrease (≥1%) in hyperandrogenemic women. Semantic connectivity maps (SCMs) were obtained through Auto-CM, a fourth generation ANN, to compare patients' baseline clinical features to the treatment outcomes. Multivariate logistic regression analysis was used to assess the major predictor in drop-out patients and the associated risk. RESULTS: At 6 months 54 out of 103 (52,4%) obese patients showed BMI reduction and 45 out of 89 (50,6%) hyperandrogenemic women showed FAI decrease. The further response rates at 12 months were 30,6 and 47%, respectively. SCMs showed a clear polarization for both the outcomes with elevated accuracy. Treatment responsiveness resulted strictly related to oligo-amenorrhea and hyperandrogenemia at baseline. In addition, lower serum testosterone levels at baseline were found to be the major predictor of treatment discontinuation. CONCLUSIONS: In women with PCOS, menstrual pattern imbalance and ovarian androgens excess are the best predictors of metformin response. They may pave the way for a rethinking of the criteria for evaluating hyperandrogenism in order to better define the large population included in the diagnosis of PCOS. Baseline plasma testosterone level can serve as a sensitive marker to predict treatment compliance.

Basal serum level of Δ4-androstenedione reflects the ovaries' ability to respond to stimulation in IVF cycles: setting up a new reliable index of both ovarian reserve and response.

PURPOSE: Adequate androgen levels are necessary for regular follicular growth, progression beyond the pre-antral stage, and prevention of follicular atresia. The main purpose of this study was to investigate whether baseline androgen levels had a predictive value on stimulation outcomes in IVF cycles. The secondary purpose was to compare the possible predictive value of androgens with that of already known markers. METHODS: The study included 91 infertile patients aged 30-45 years awaiting the first IVF cycle. All women underwent the same stimulation protocol and the same starting dose of recombinant FSH. As stimulation outcomes, the number of follicles recruited, estradiol and progesterone levels on the day of trigger, the total dose of gonadotropins administered, and the number of oocytes collected were recorded. Multiple linear regression and multivariate logistic regression were used to evaluate the significant predictive value of the variables for response to controlled ovarian stimulation (COS). By studying the reliability of different markers, an attempt was made to develop a single index with the highest predictive value. RESULTS: Pearson's correlation revealed a statistically significant inverse correlation between oocytes collected and age (r = - 0.333, p < 0.001) and a positive correlation with AMH (anti-müllerian hormone) (r = 0.360, p < 0.001), antral follicle count (AFC) (r = 0.639, p < 0.001), and androstenedione (Δ4-A) (r = 0.359, p < 0.001). No significant correlation was reported with FSH (r = - 0.133, p = 0.207) and total testosterone (r = 0.180, p = 0.088). In COS good responders, the G-index (= AMH ng/mL*AFC/Δ4-A ng/dL) revealed a significantly higher level (p < 0.001) than AMH, AFC, and Δ4-A alone. CONCLUSION: Baseline serum Δ4-A, presumably crucial for ensuring a regular follicular growth, is a reliable marker of ovarian response to stimulation. Since the ovarian capacity to respond to gonadotropins does not depend exclusively on the presence of follicles, we suggest a new index, the G-index, able to contemplate both the ovarian reserve and the Δ4-A level.

Percutaneous microwave ablation of uterine fibroids: correlation between shrinkage and trend symptoms.

PURPOSE: To assess a correlation between the shrinkage of the fibroid and the course of the symptoms. MATERIAL AND METHODS: Fourteen patients with symptomatic uterine leiomyomas (mean fibroid volume: 111.45 cm3) underwent percutaneous microwave ablation. Contrast-enhanced MRI follow-up was performed before and after treatment to evaluate the volume shrinkage. Two scores obtained from the Uterine Fibroids Symptom and Quality of Life questionnaire were used to perform a clinical follow-up to evaluate the symptoms and the quality of life at baseline, and at 3, 6 and 12 months after treatment. RESULTS: All patients were treated, no complications occurred. During a mean MR follow-up of 8.1 months we observed shrinkage of the fibroids in all patients (mean 70.3 cm3). During 12 months clinical follow-up, we observed a significant improvement of symptoms and an excellent improvement of quality of life (p < .001). CONCLUSION: Uterine fibroids percutaneous microwave ablation is a safe tool to obtain a significant improvement in quality of life for all the patients of our cohort.

COVID-19 does not stop obstetrics: what we need to change to go on safely birthing. The experience of a University Obstetrics and Gynecology Department in Milan.

Since SARS-COV-2 appeared in Wuhan City, China and rapidly spread throughout Europe, a real revolution occurred in the daily routine and in the organization of the entire health system. While non-urgent clinical services have been reduced as far as possible, all kind of specialists turned into COVID-19 specialists. Obstetric assistance cannot be suspended and, at the same time, safety must be guaranteed. In addition, as COVID-19 positive pregnant patients require additional care, some of the clinical habits need to be changed to face emerging needs for a vulnerable but unstoppable kind of patients. We report the management set up in an Obstetrics and Gynecology Unit during the COVID-19 era in a University Hospital in Milan, Italy.

Use of high-frequency ultrasound to study the prenatal development of cranial neural tube defects and hydrocephalus in Gldc-deficient mice.

OBJECTIVE: We used non-invasive high-frequency ultrasound (HFUS) imaging to investigate embryonic brain development in a mouse model for neural tube defects (NTDs) and non-ketotic hyperglycinemia (NKH). METHOD: Using HFUS, we imaged embryos carrying loss of function alleles of Gldc encoding glycine decarboxylase, a component of the glycine cleavage system in mitochondrial folate metabolism, which is known to be associated with cranial NTDs and NKH in humans. We serially examined the same litter during the second half of embryonic development and quantified cerebral structures. Genotype was confirmed using PCR. Histology was used to confirm ultrasound findings. RESULTS: High-frequency ultrasound allowed in utero detection of two major brain abnormalities in Gldc-deficient mouse embryos, cranial NTDs (exencephaly) and ventriculomegaly (corresponding with the previous finding of post-natal hydrocephalus). Serial ultrasound allowed individual embryos to be analysed at successive gestational time points. From embryonic day 16.5 to 18.5, the lateral ventricle volume reduced in wild-type and heterozygous embryos but increased in homozygous Gldc-deficient embryos. CONCLUSION: Exencephaly and ventriculomegaly were detectable by HFUS in homozygous Gldc-deficient mouse embryos indicating this to be an effective tool to study CNS development. Longitudinal analysis of the same embryo allowed the prenatal onset and progression of ventricle enlargement in Gldc-deficient mice to be determined. © 2017 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

De novo ceramide synthesis is involved in acute inflammation during labor.

Gestation is regulated by an inflammatory process that allows implantation and parturition. The comprehension of such inflammatory switches is important for the identification of therapeutic targets in pregnancy defects. Sphingolipids are a class of structural membrane components with important signaling functions. Among sphingolipids, ceramide is a well-known mediator of stress signals and pro-inflammatory responses. In this paper, we evaluated the association between ceramide increase and the inflammatory process of labor, comparing placentas from vaginal deliveries, including both spontaneous and induced labor, versus elective cesarean. We demonstrated that: (i) the inflammatory marker IL-6 is upregulated in labored placentas; (ii) IL-6 content inversely correlates with labor duration; (iii) ceramide content and expression of serine palmitoyl transferase (SPT, rate limiting enzyme for de novo ceramide synthesis) are increased in labored placentas; (iv) the expression of SPT directly correlates with inflammation and inversely with labor duration. These observations suggest that ceramide metabolism and signaling may be implicated in controlling important inflammatory mechanisms driving gestation: we hypothesize that ceramide can be a therapeutic target in inflammatory complications of parturition.

Cell death and cell proliferation in human spina bifida.

BACKGROUND: Spina bifida is a multifactorial congenital malformation of the central nervous system. The aim of this study was to ascertain the relevance of cell death/proliferation balance in human spina bifida and to assess autophagy distribution and levels during embryo-fetal development in neural tissue. METHODS: Five human cases with myelomeningocoele were compared with 10 healthy human controls and LC3 protein expression was also analyzed in mouse embryos. Cell death was evaluated using TUNEL (terminal deoxynucleotidyl transferase-mediated deoxyuridinetriphosphate nick end-labeling) assay; cell proliferation was studied by counting Ki67-positive cells, and autophagy was assessed by observing the presence of LC3 punctuate dots. RESULTS: Comparing human cases and controls (13 to 21 weeks of gestation), we observed a significant increase in TUNEL-positive cells in human spina bifida associated with a significantly decreased proliferation rate, indicating an alteration of the physiological cell rate homeostasis. LC3 distribution was found to be spatiotemporally regulated in both human and murine embryo-fetuses: in early pregnancy a diffuse and ubiquitous LC3 signal was detected. After neural tube closure, an intense LC3-positive signal, normally associated to extra energy requirement, was confined to the Lissauer's tract, the dorsolateral spinal zone containing centrally projecting axons from dorsal root ganglia, at any medullar levels. LC3 signal disappeared from 12 weeks of gestation. CONCLUSION: In conclusion, this study confirms the fundamental role of cell death/proliferation balance during central nervous system development and reports the changing expression of LC3 protein in mouse and human neural tube. Birth Defects Research (Part A) 106:104-113, 2016. © 2015 Wiley Periodicals, Inc.

Chronobiology, sleep-related risk factors and light therapy in perinatal depression: the "Life-ON" project.

BACKGROUND: Perinatal depression (PND) has an overall estimated prevalence of roughly 12 %. Untreated PND has significant negative consequences not only on the health of the mothers, but also on the physical, emotional and cognitive development of their children. No certain risk factors are known to predict PND and no completely safe drug treatments are available during pregnancy and breastfeeding. Sleep and depression are strongly related to each other because of a solid reciprocal causal relationship. Bright light therapy (BLT) is a well-tested and safe treatment, effective in both depression and circadian/sleep disorders. METHODS: In a 3-year longitudinal, observational, multicentre study, about 500 women will be recruited and followed-up from early pregnancy (10-15 gestational week) until 12 months after delivery. The primary aim of the present study is to systematically explore and characterize risk factors for PND by prospective sleep assessment (using wrist actigraphy, polysomnography and various sleep questionnaires) and bloodbased analysis of potential markers during the perinatal period (Life-ON study). Secondary aims are to explore the relationship between specific genetic polymorphisms and PND (substudy Life-ON1), to investigate the effectiveness of BLT in treating PND (substudy Life-ON2) and to test whether a short term trial of BLT during pregnancy can prevent PND (substudy Life-ON3). DISCUSSION: The characterization of specific predictive and risk factors for PND may substantially contribute to improve preventive medical and social strategies for the affected women. The study results are expected to promote a better understanding of the relationship between sleep disorders and the development of PND and to confirm, in a large sample of women, the safety and efficacy of BLT both in prevention and treatment of PND. TRIAL REGISTRATION: ClinicalTrials.gov NCT02664467 . Registered 13 January 2016.

The experience of meditation for people with amyotrophic lateral sclerosis and their caregivers - a qualitative analysis.

There is a lack of studies about psychological interventions for people with amyotrophic lateral sclerosis (ALS) and their caregivers. We investigated the experience of a meditation training program tailored for ALS needs. People with ALS (pALS) and their caregivers that joined a meditation program for ALS were interviewed at the end of the program. Verbatims were analyzed with a qualitative approach. Both pALS and their caregivers reported a positive impact on their psychological well-being, promoted by an increase in acceptance and non-judgmental attitude. Furthermore, coping strategies seem to improve, with a positive effect on resilience skills. The ALS meditation training program seems to be an effective psychological intervention for the promotion of well-being in pALS and their caregivers.

Atazanavir and lopinavir profile in pregnant women with HIV: tolerability, activity and pregnancy outcomes in an observational national study.

BACKGROUND: Atazanavir and lopinavir represent the main HIV protease inhibitors recommended in pregnancy, but comparative data in pregnant women are limited. METHODS: Women from a national observational study, exposed in pregnancy to either atazanavir or lopinavir, were compared for glucose and lipid profiles, liver function tests, CD4 count, HIV RNA and main pregnancy outcomes. Statistical methods included univariate and multivariable analyses. RESULTS: The study population included 428 pregnancies (lopinavir, 322; atazanavir, 106). The lopinavir group was characterized by higher rates of HIV diagnosis in pregnancy and treatment indication for maternal health, lower CD4 counts, higher HIV RNA levels, less frequent antiretroviral treatment at conception and shorter duration of drug exposure during pregnancy. No differences in pregnancy outcomes, glucose metabolism and weight gain were observed. The two groups also showed in a multivariable analysis similar odds for detectable HIV RNA in the third trimester (adjusted OR 0.85, 95% CI 0.35-2.10, P = 0.730). Total lipid levels were significantly higher in the lopinavir group (median values in the third trimester 239 versus 221 mg/dL for total cholesterol and 226 versus 181 mg/dL for triglycerides; P < 0.001 for both comparisons) and bilirubin levels were significantly higher in the atazanavir group (1.53 versus 0.46 mg/dL, P < 0.001). CONCLUSIONS: In this observational study atazanavir and lopinavir showed similar safety and activity in pregnancy, with no differences in the main pregnancy outcomes. Atazanavir use was associated with a better lipid profile and with higher bilirubin levels. Overall, the study findings confirm that these two HIV protease inhibitors represent equally valid alternative options.

New horizons in gynecological surgery: first-year experience with HUGO™ robotic-assisted surgery system at two tertiary referral robotic centers.

The HUGO™ robotic-assisted surgery system (RAS, Medtronic, CA) consists of a 3D open console, four independent carts, and an integrated laparoscopic and robotic tower. Approved in 2021, it represents a novel alternative platform for robotic procedures. The aim of our study is to report the first-year experience with this system for gynecological procedures at two tertiary referral robotic centers. We prospectively collected and retrospectively analyzed data from patients underwent gynecological robot-assisted surgery with the HUGO™ RAS, at San Paolo University Hospital (Milan, Italy), and Onze Lieve Vrouw (OLV) Hospital (Aalst, Belgium), March 2022-April 2023. Demographic characteristics, intraoperative settings, and perioperative outcomes were investigated. A total of 32 procedures were performed: 20 (62.5%) hysterectomies, 7 (21.9%) adnexal surgeries, and 5 (15.6%) pelvic floor reconstructive surgeries. In 2022 and 2023, 13 (40.6%) and 19 (59.4%) procedures were carried out, respectively. The median docking time was 8 min (IQR 5.8-11.5). The median console and skin-to-skin time was 52.5 min (IQR 33.8-94.2) and 108.5 min (IQR 81.5-157.2), respectively. No intraoperative complications occurred. Two conversions to laparoscopy managed without any additional complications were needed. To the best of our knowledge, this is the first global series of gynecological procedures performed with the HUGO™ RAS. Our preliminary findings showed the system's feasibility reporting promising results. The observed upward trend in the total number of procedures during the analyzed period is encouraging. Further studies are needed to assess a standardized method in the gynecological field with the novel platform.

Sleep and sleep disorders during pregnancy and postpartum: The Life-ON study.

OBJECTIVE: to prospectively assess sleep and sleep disorders during pregnancy and postpartum in a large cohort of women. METHODS: multicenter prospective Life-ON study, recruiting consecutive pregnant women at a gestational age between 10 and 15 weeks, from the local gynecological departments. The study included home polysomnography performed between the 23rd and 25th week of pregnancy and sleep-related questionnaires at 9 points in time during pregnancy and 6 months postpartum. RESULTS: 439 pregnant women (mean age 33.7 ± 4.2 yrs) were enrolled. Poor quality of sleep was reported by 34% of women in the first trimester of pregnancy, by 46% of women in the third trimester, and by as many as 71% of women in the first month after delivery. A similar trend was seen for insomnia. Excessive daytime sleepiness peaked in the first trimester (30% of women), and decreased in the third trimester, to 22% of women. Prevalence of restless legs syndrome was 25%, with a peak in the third trimester of pregnancy. Polysomnographic data, available for 353 women, revealed that 24% of women slept less than 6 h, and 30.6% of women had a sleep efficiency below 80%. Sleep-disordered breathing (RDI≥5) had a prevalence of 4.2% and correlated positively with BMI. CONCLUSIONS: The Life-ON study provides the largest polysomnographic dataset coupled with longitudinal subjective assessments of sleep quality in pregnant women to date. Sleep disorders are highly frequent and distributed differently during pregnancy and postpartum. Routine assessment of sleep disturbances in the perinatal period is necessary to improve early detection and clinical management.

Robotic multiple sigmoid and rectal mucosa skinning in a multicentric deep infiltrating bowel endometriotic nodules: a case report.

Endometriosis is a benign gynecological disease characterized by the presence of endometrial tissue outside the uterus. The eradication of non-gynecological localizations represents the real surgical challenge. A 29-year-old woman underwent robotic surgery with the Da Vinci system (Intuitive Surgical Inc.) for a diagnosis of stage IV deep endometriosis. The patient presented with 5 cm left ovarian endometrioma, an infiltration of the left posterior parametrium, and bilateral ureteral endometriosis. Once inside the pelvic cavity, deep intestinal infiltrating endometriosis implants were confirmed as triple, multicentric, and multifocal lesions, affected distal sigmoid, rectosigmoid junction, and upper rectum. An expert multiple excision, sparing the intestinal mucosa, was performed. To our knowledge, this is the first description of a multiple robotic shaving of multicentric endometriotic intestinal lesions. After the surgery, a normal diet was quickly restored, accelerating the recovery of the physiological peristalsis and the overall recovery time.

Increasing Vaccine Uptake during Pregnancy by Using Prenatal Education Classes: An Effective Tool for Health Communication and Promotion.

Childbirth education classes represent an antenatal tool for supporting pregnant women and couples in increasing knowledge on pregnancy, delivery, breastfeeding, and newborn care. The aim of this study was to investigate the impact of an additional lesson during the prenatal course regarding the advantage of vaccination to mitigation of maternal anxiety. An observational study was designed that included participants in childbirth education classes and compared courses enhanced by the extra lesson on vaccination during pregnancy versus those who did not receive it. Assessment of the impact of prenatal educational on vaccination was measured by using validated questionnaires (State-Trait Anxiety Inventory, STAI; Perceived Stress Scale, PSS; World Health Organization- Five Well-Being Index, WHO-5). A total of 145 pregnant women participated to the investigation by answering to the online survey. Of them, 33 patients (22.8%) belonged to the course without a lesson on vaccine, while 112 (77.2%) participated to online prenatal education that included an additional meeting on the usefulness of getting vaccinated during pregnancy. No statistical differences were found between study groups in terms of demographics and perinatal outcomes. Participants in the enriched course reported lower basal anxiety levels than those without the vaccine lesson (STAI-State, normal score < 40, 30 vs. 19%, p-value 0.041; STAI-State, mild score 40-50, 78 vs. 67%, p-value 0.037). With reference to the prior two weeks, maternal wellbeing level was improved by the added class (score > 13 as measurement of wellbeing: 62% vs. 80%, p-value < 0.05). Moderate perceived stress assessed by PSS was found in those pregnant women without prenatal education on vaccination (64 vs. 50%, p-value 0.042). The introduction of a lesson regarding vaccination during pregnancy in the program of prenatal education courses improved maternal anxiety levels and wellbeing, in addition to reducing perceived stress.

Prior Robotic Console Expertise May Improve Basic Skills at the New Hugo RAS Simulator: Results from a Cohort Trial and Implications for Skill Transference Across Platforms.

Background: Robot-assisted surgery ensures minimal invasiveness; since the expiry of the Da Vinci patent, new robotic systems have entered the market. Recently, the Hugo RAS received CE approval for several surgical procedures. However, more is needed to know about skill acquisition at the new simulator. Objective: This study aims to analyse the factors impacting basic surgical skills at the Hugo RAS simulator. Design setting and participants: We present a cross-sectional study involving 71 participants of different backgrounds invited to a hands-on session with the Hugo RAS simulator voluntarily. All of them had no prior expertise with the system. Participants were recruited among medical/nurse students, residents, and laparoscopic and robotic surgeons. Intervention: All participants underwent a hands-on "pick and place" exercise at the Hugo RAS simulator; the metrics of a second-round pick and place exercise were recorded. Outcome measurements and statistical analysis: Metrics were analysed with regard to the following variables: demographics, videogame use, and prior surgical experience (no surgical expertise, experience with laparoscopy, and experience with robotic console). Results and limitations: All participants completed the test. Of them, 77.5% were naïve to surgery, 8.5% had prior laparoscopic expertise, and 14.1% had prior robotic console experience. The time to complete the pick and place exercise was significantly lower (p < 0.001) among prior robotic surgeons (38 s, interquartile range [IQR] 34-45) compared with both naïve participants (61 s, IQR 53-71) and laparoscopists (93 s, IQR 53-162). The overall score of the exercise decreased with age (p = 0.046); however, the overall scores were significantly and steadily higher among surgeons experienced in robotic consoles across all age groups (p = 0.006). Neither gender (p = 0.7) nor videogame use (p = 0.9) correlated significantly with the metrics. Conclusions: This is the first study analysing factors impacting basic skill acquisition at a new robotic simulator. Experience with robotic consoles may represent a major factor, raising the hypothesis of the transferability of basic robotic skills across different robotic systems. Further studies are required to explore this issue. Patient summary: In the present study, we analysed which characteristics may affect the basic surgical skills at a novel robotic platform.

Impact of hands-on practice with HugoRAS and Versius System simulators on the attractiveness of robotic surgery among medical and nurse undergraduate students.

The scenario of robotic surgery is rapidly evolving with the introduction of new robotic systems. A structured learning program in robotic surgery during academic education is often lacking, especially for undergraduates; as a result, many students may be unaware of indications to robotic surgery and technological progress. The aim of the study is to evaluate the knowledge and interest toward robotic surgery of medical and nurse students, and to analyze how the attractiveness may change after a hand-on training course with new simulators of Hugo RAS and Versius System. We performed a cross-sectional study involving medical and nurse students recruited on a voluntary basis at ASST Santi Paolo and Carlo, Milan; participants were invited to join a hands-on practice simulation with the Hugo RAS and/or Versius Trainer Simulator. Before the hand-on exercise, students were asked to fulfill an online anonymous questionnaire addressing knowledge and interest toward robotic surgery. After a 2-h hands-on exercises at the Hugo RAS and/or at the Versius Trainer simulator (preceded by a brief lecture on robotic surgery and new systems), participants were asked to complete a second-round questionnaire to evaluate changes in attractiveness toward robotic surgery. Data were recorded in a database; after a descriptive analysis of the variables, median values were compared with the Mann-Whitney U test, frequencies with the Fisher's exact test and in the case of paired observations (before and after the simulation), the Mc Nemar test was used. Forty-one undergraduates agreed to participate. Twenty-three nursing students and 18 medical students were recruited. Some of them had a basic knowledge in robotic surgery and were able to figure out some surgical indications, given the presence of a robotic program already settled up at the institution. Before the hands-on course, 44.0% nurse students and 36.6% of medical students were interested in surgical disciplines and robotic surgery. After the simulation, all students (100%) reported a high level of interest in robotic surgery and some of them required for a dedicated internship (p < 0.001). The students provided also feedback on the perceived ease-of-use of the robotic simulators (on a scale 0-10); overall, the median score was 8, IQR [7-8], with no differences between nursing and medical students (p = 0.482). In conclusion, the study demonstrates a great interest toward robotic surgery as a part of medical and nurse education. A hands-on simulation further improved the interest of undergraduates from both backgrounds. The technological progress with the availability of new surgical systems will be the future challenge of training programs and should be considered at all levels of education.

Aggressiveness, sexuality, and obsessiveness in late stages of ALS patients and their effects on caregivers.

Clinical experience has shown an increase of behavioural and mood symptoms, especially in the areas of aggressiveness, sexuality and obsessiveness, during the late stages of ALS. The lack of conclusive data concerning these symptoms prompted us to assess the psychological aspects of ALS patients in advanced stages of the disease. Moreover, we evaluated the personality of their caregivers in order to analyse the relationship between the pair. For these purposes, we studied 10 patients with ALS in late stages (tracheostomized for 36 months) and their caregivers using a questionnaire specifically elaborated for patients' communication limits. To assess the state of anxiety and depression of both patients and caregivers, we used the Hospital Anxiety and Depression Scale (HADS). To investigate caregivers' personality, we administered the Big Five Questionnaire (BFQ). Data showed a trend of aggression and high level of obsessiveness in ALS patients, associated with several clinical characteristics. High levels of anxiety emerged in both patients and caregivers. Regarding BFQ, caregivers obtained higher scores in the dimension of Conscientiousness and very low scores in Extraversion and Emotional Stability. In conclusion, the study showed a potential and considerable effect of the long duration of ALS on patients' personality and caregivers' distress.