Robot-assisted partial nephrectomy using the novel Hugo™ RAS system: Feasibility, setting and perioperative outcomes of the first off-clamp series.

INTRODUCTION: Hugo Robot-Assisted Surgery (RAS) System has been conceived with enhanced modularity but its role for nephron-sparing surgery setting still remains poorly explored. We aimed to describe our experience in robot-assisted partial nephrectomy (RAPN) with a three-arms setting for the first off-clamp series using the new Hugo RAS System. METHODS: Patients were placed on an extended flank position at the margin of the surgical bed with a slightly flexion (45°). The first 11 mm robotic trocar (camera port) was placed along the pararectal line 14 ± 2 cm far from the umbilicus. The pneumoperitoneum was then induced through the AirSeal system (SurgiQuest, Milford, Connecticut, USA©). Two more 8 mm operative robotic ports were placed under direct vision, either 8 ± 1 cm far from optic's port. Two 12 mm laparoscopic ports for bed-assistant were placed between robotic ports. Monopolar curved shears, fenestrated grasper, and large needle driver were used in a three-instruments configuration. RESULTS: Off-clamp RAPN was successfully performed in seven patients with cT1 renal masses using a trans-peritoneal route. Median port placement and docking time was 6 min (IQR, 4-8 min). Hemostasis was achieved through renorraphy using a single transfix stitch with sliding clips technique. There was no need for additional ports placement. No intraoperative complications occurred, no clashing of robotic instruments or between the robotic arms was observed. No technical failures of the system occurred. Median console time was 83 min (IQR, 68-115 min). Median estimated blood loss were 200 ml (IQR, 50-400 ml). All patients were discharged between post-operative day 2 and 3, without the need of hospital readmission. No complications were recorded within the first 30 post-operative days. CONCLUSIONS: We performed the first series of off-clamp RAPN using the novel HUGO RAS System. This novel robotic platform showed an easy-friendly docking system, providing excellent perioperative outcomes with a simple three-arms configuration.

[Medical therapy of portal hypertension due to liver cirrhosis]. / Terapia medica dell'ipertensione portale da cirrosi epatica.

Several vasoactive agents are known to reduce portal pressure and therefore are potentially useful in the treatment of portal hypertension. These drugs act in different ways and seem to have several actions. In most cases, their exact mechanisms have not yet been elucidated and more investigations are required. Different pharmacologic treatments of portal hypertension may result from these hemodynamic studies but more trials are required in the forthcoming years.

The therapeutic effect of L-carnitine in patients with exercise-induced stable angina: a controlled study.

An investigation on the therapeutic effect of L-carnitine was performed at three different centres and included two hundred patients, 40 to 65 years of age, with exercise-induced stable angina. In one hundred randomly selected patients the drug was administered orally in daily doses of 2 g in addition to the already instituted therapy, and the effect studied over a 6-month period. Compared with the control group, these patients showed a significant reduction in the number of premature ventricular contractions (PVC) at rest, as well as an increased tolerance during ergometric cycle exercise as demonstrated by an increased maximal cardiac frequency, increased maximal systolic arterial blood pressure and therefore also increased double cardiac product and reduced ST-segment depression during maximal effort. This was accompanied by improvement in cardiac function and resultant performance, as shown by an increase in the number of patients belonging to class I of the NYHA classification and a reduction in the consumption of cardioactive drugs. Laboratory analysis showed an improvement in plasma lipid levels. The authors conclude, after having discussed the particular metabolic mechanisms, that L-carnitine undoubtedly represents an interesting therapeutic drug for patients with exercise-induced stable angina.

Gastric lymphoma: diagnosis and follow-up of chemotherapy-induced changes using real-time ultrasonography: a report of three cases.

Three cases of secondary gastric lymphoma are presented in which diagnosis was suggested by ultrasound (US) and confirmed by endoscopy and microscopical examination. Three different US patterns are illustrated and compared with endoscopy. US findings paralleled endoscopy during follow-up under antiblastic treatment: both improvement and lack of change in the gastric lesions were reliably predicted by US.

Recovery of low thymic hormone levels in cancer patients by lysine-arginine combination.

Thymic hormones are required for maturation and maintenance of the immune efficiency. It has been previously demonstrated that with advancing age there occurs a progressive reduction of the plasma level of one of the best known thymic peptides, i.e. thymulin, and that the administration of an amino acid combination (lysine-arginine, as present in the commercial preparation Lysargin, Baldacci, Italy) to elderly individuals is able to increase the synthesis and/or release of thymulin to values comparable to those recorded in young subjects. In the present paper we report evidence that cancer patients show much lower thymulin values than those recorded in healthy age-matched individuals and that the oral administration of the amino acid preparation is able to significantly increase thymulin levels even over the values of age-matched controls and to increase the number of peripheral T-cell subsets. It is suggested that such an effect is mediated through the known secretagogue activity of the amino acids on the pituitary release of growth hormone, which has a modulating effect on the thymic endocrine activity.

Regression of left ventricular hypertrophy and systolic function in hypertensive patients during long-term treatment with ketanserin.

It is now generally accepted that antihypertensive therapy can induce regression of left ventricular hypertrophy (LVH) in hypertensive subjects. However, the influence of LVH reversal on both the systolic and diastolic functions, and particularly the ability of the heart to meet sudden overloads caused by exercise and/or recurrence of hypertension, remain unanswered questions. The long-term effects of ketanserin, a selective serotonin S2-receptor antagonist with additional alpha 1-adrenergic blocking properties, on LVH and systolic function were studied in 13 untreated subjects (age range 35-55 years) with mild-to-moderate essential hypertension, echocardiographic evidence of LVH, and normal ejection fraction. Blood pressure values and echocardiographic measurements of dimensions, wall thicknesses, and indices of LV mass were determined before and after 3, 6, and 12 months treatment; ejection fractions at rest and during exercise were evaluated by equilibrium multigated radionuclide angiocardiography at baseline and after 12 months of therapy. Mean arterial pressure was significantly reduced from the first month of treatment (p less than 0.001) and remained well controlled up to the end of the trial. Both posterior and septum wall thicknesses decreased after 3 months of therapy and remained stable throughout the whole study period. LV mass index decreased from a mean +/- SD of 187.7 +/- 47.6 g/m2 to a mean of 157.81 +/- 31.63 g/m2 (p less than 0.01) at the third month, reaching greater decreases after 6 months (156.05 +/- 31.00 g/m2) and after 12 months (153.21 +/- 28.80 g/m2) of treatment. A significant correlation was found between LV mass and posterior wall thickness at the different observation times in the study. Finally, the regression of LVH at the end of therapy was not associated with impairment of systolic function, as assessed by measurements of ejection fraction at rest and during exercise.

[Alcoholic liver diseases and their treatment]. / Le malattie del fegato alcol-correlate e il loro trattamento terapeutico.

Alcohol abuse is widespread and alcoholic liver disease represents a major medical and social problem. The spectrum of alcoholic liver injury is currently grouped into three clinical forms: fatty liver, alcoholic hepatitis and cirrhosis. The rational management of alcoholic liver disease can be divided in non-specific therapy and in specific treatment. The most important aspect of non-specific therapy is cessation of alcohol consumption: the abstinence diminishes symptoms and improves signs, and significantly increases survival. As to specific treatment, a number of controlled clinical trials of various forms of therapy have been carried out. Steatosis is spontaneously reversible after cessation of alcohol consumption, and therefore no treatment is necessary. For hepatitis, a number of protocols have been studied with both low and high doses of corticosteroids, cyanidanol, penicillamine, synthetic thyroid antagonists, hormones, and amino acids. Results have been negative, disappointing, or contradictory. In cirrhosis, corticosteroids and colchicine have been used: the former were ineffective while clinical and histological improvement as well as reduced mortality were obtained with the latter. Especially interesting results were registered after treatment with polyunsaturated phosphatidylcholine which has been used for steatosis, acute hepatitis and cirrhosis with good clinical, histological, and biohumoral findings.

Serum neopterin levels in liver cirrhosis.

Neopterin is a pyrazino-pyrimidine compound which is biosynthesized by macrophages. Increased concentrations of neopterin have been reported in conditions causing a stimulation of cellular immunity, such as viral and other infections, graft versus host disease, autoimmune disease and different malignancies. Recently, urinary neopterin levels have been found increased in patients with acute viral hepatitis and NANB chronic hepatitis. In the present study, neopterin serum levels have been measured in 23 cirrhotic patients (6 HBV related, and 17 cryptogenetic cirrhosis, 7 of them occurring in alcoholic subjects) and in 24 normal subjects. Mean values of serum neopterin were significantly increased in cirrhotics (3.92 +/- 3.28 ng/ml versus 1.24 +/- 0.51 ng/ml in controls, p less than 0.01). Serum neopterin values were not found to be significantly different in cirrhotics assessed in three different clinical classes according to Child's classification and in cirrhotics with and without serological findings of active disease. In fact, in cirrhotic patients, serum neopterin levels did not correlate with the values of serum AST, ALT, ALP, GGT and gamma-globulin. These data show that increased levels of serum neopterin occur in cirrhotic patients, but there is no relation between serum neopterin values and the activity or the clinical severity of the disease. The results are consistent with the hypothesis that activated macrophages are involved in all stages of liver cirrhosis irrespective of its aetiology.

Clinical efficacy of picotamide in long-term treatment of intermittent claudication.

The clinical efficacy of picotamide was investigated in a randomized, double-blind, placebo-controlled study in patients with peripheral occlusive arterial disease of the lower limbs at functional stage II of the Fontaine classification. Forty patients with a history of claudication for at least six months were admitted to the study and were given either 3 x 300 mg tablets of picotamide (20 subjects) or three identical placebo tablets (20 subjects) for six months. The two groups of patients were similar in regard to clinical features and potential risk factors. At the end of treatment painfree walking distance and systolic ankle-arm pressure ratio improved more in the picotamide than in the placebo group (p = 0.05). Systolic ankle pressure curves, determined before and after the six-month treatment, showed a positive trend to a higher postexercise ankle pressure and a faster return to the preexercise levels in the picotamide group; however, the difference was not statistically significant. Laboratory monitoring revealed a slight prolongation of bleeding time, a significant decrease in arachidonic acid-induced platelet aggregation, and an enhanced fibrinolysis with absence of interference with hemostasis in the picotamide group. One patient in the placebo group developed a major cardiovascular event (angina pectoris) during the study. These results indicate that picotamide is an effective drug that may modify the natural course of intermittent claudication and associated vascular problems.

Insulin and glucagon degradation in liver are not affected by hepatic cirrhosis.

Hyperinsulinemia and impaired glucose tolerance are associated with liver cirrhosis. To investigate whether insulin-degrading activity in liver tissue plays a role in hyperinsulinemia, we assayed this activity in biopsy tissue from healthy and cirrhotic subjects. There was no difference in insulin degradation between these two groups. Also glucagon-degrading activity in liver tissue, which is catalyzed by the same enzyme as insulin-degrading activity, did not differ between the two groups studied. Therefore, insulin-degrading activity does not appear to be involved in the hyperinsulinemia that occurs in liver cirrhosis. The study provides indirect evidence that hyperinsulinemia and impaired glucose metabolism in liver cirrhosis are due to different mechanisms (receptorial and post-receptorial defects, and altered feedback inhibition of insulin secretion).

[Blood levels of neopterin in patients with liver cirrhosis]. / Studio dei livelli sierici di neopterina in pazienti con cirrosi epatica.

Neopterin is a pyrazino-pyrimidine compound which is biosynthesized by macrophages. Increased concentrations of neopterin have been reported in conditions causing stimulation of cellular immunity, such as viral and other infections, graft versus host disease, autoimmune diseases and different malignancies. Recently, increased urinary neopterin levels have been found in patients with acute viral hepatitis and NANB chronic hepatitis. In the present study, neopterin serum levels were measured in 23 cirrhotic patients (6 HBV related, 7 alcoholic and 10 cryptogenetic cirrhosis) and in 24 normal subjects. Mean values of serum neopterin were statistically increased in cirrhotics (3.92 +/- 3.28 ng/mL versus 1.24 +/- 0.51 ng/mL in controls, p less than 0.01). Serum neopterin values were not statistically different either in cirrhotics assessed in three different classes according to Child's classification or in cirrhotics with or without serological findings of active disease. In fact, in cirrhotic patients, serum neopterin levels did not correlate with serum aspartate and alanine aminotransferases, alkaline phosphatase, gamma-glutamyltransferase and gammaglobulins values. These data show that increased levels of serum neopterin occur in cirrhotic patients, but there is no relation between serum neopterin values and the histological activity or the clinical severity of the disease. The results are consistent with the hypothesis that activated macrophages are involved in all forms and in all stages of liver cirrhosis.

Hepatitis B virus infection among health care workers at an urban teaching hospital in southern Italy: a low occupational hazard?

A prevalence study of HBV serologic markers was carried out among hospital employees of ten departments of the Second School of Medicine in Naples, an urban area with a high prevalence of HBV infection. Departments and occupational categories were selected to represent a spectrum of different exposure to B virus infection. Workers in a large electronic plant in the same geographical area were screened as controls. HBsAg prevalence was 4.8% in the hospital community and 4.0% in control group. It rises to 4.3% in the Campania Region, where all screened workers live, and in some specific areas of the same region it rises to 12%. But no significant difference among seropositivities for at least 1 marker of HBV, considered to be a better indicator of occupational hazard, was found among personnel of different departments or belonging to different occupational categories. None of the occupational and non-occupational risk factors studied was found to be significantly associated with HBV infection. Two years later, an incidence study was carried out among susceptible subjects. Seropositivity for 1 marker was 2.2% among hospital workers and 2.8% in the control group. These figures are lower than the annual attack rate (5%) required for an acceptable cost-benefit ratio of vaccination against hepatitis B. Our results indicate that in a geographical area with HBV endemicity the occupational hazard for B virus infection is low in hospital workers because of the high number of the high number of immunized subjects and the contacts with infected people out of the hospital.

Clinical investigation of the effect of ketanserin: a new antihypertensive drug.

The antihypertensive effect of a recently introduced antiserotoninic drug, ketanserin, was examined in a single-blind, placebo-controlled parallel group study in 28 patients with mild to moderate hypertension. Supine and standing blood pressure, electrocardiogram, heart rate and laboratory parameters of liver, kidney and bone marrow functions were checked before and after 3 months of treatment. After 12 weeks' treatment with ketanserin (20-40 mg twice a day), there was a highly significant reduction of both systolic and diastolic blood pressure, as compared to placebo in the supine position (p less than 0.0001/p less than 0.001). In the standing position, the reduction of systolic pressure was more significant than the diastolic pressure (p less than 0.0001/p less than 0.01). Eleven out of 28 hypertensive patients showed electrocardiographic evidence of left ventricular hypertrophy (LVH) according to the ECG criteria of Romhilt and Estes. Although a reduction of the mean point score for LVH as compared to placebo was observed in the ketanserin group, that difference was not statistically significant. These preliminary observations suggest a possible role of ketanserin in the regression of LVH due to essential hypertension.

Beta-hexosaminidase activity in alcoholic fatty liver and in CCl4-induced liver fibrosis of the rat.

beta-Hexosaminidase (Hex) activity was previously found to be increased in the sera of patients with liver cirrhosis, cholestasis and acute alcohol intoxication, as well as in rats with CCl4-induced liver cirrhosis. We studied this enzymatic activity in the sera and liver tissue of rats with alcoholic fatty liver due to prolonged alcohol intake and CCl4-induced liver fibrosis in association with moderate alterations in liver function tests. Serum and liver Hex activity did not show any significant change in both experimental models. These data suggest that Hex is not an alcohol-induced enzyme, and that severe, but not moderate, liver damage can determine the increase in this lysosomal enzymatic activity.

Abnormalities of glucose metabolism induced by liver cirrhosis and glycosylated hemoglobin levels in chronic liver disease.

UNLABELLED: The prevalence of impaired glucose tolerance (IGT) and diabetes mellitus (DM) such as defined by National Diabetes Data Group criteria, and glycosylated hemoglobin levels were assessed in a series of consecutive patients who had chronic active hepatitis (CAH) or cirrhosis in the absence of any known diabetogenic risk factors and who had normal fasting glycemic levels. Based on oral glucose tolerance test, the prevalence of IGT (15%) and DM (27%) in cirrhosis was significantly higher (p less than 0.005) than that observed in CAH (0%) and controls (0%). In contrast, HbA1 levels were not statistically different in cirrhotic patients (with normal or altered glucose tolerance) as compared with CAH and control subjects. IN CONCLUSION: (a) HbA1 is an unsatisfactory test in the diagnosis of altered glucose tolerance in patients with cirrhosis, and (b) Cirrhosis (but not CAH) represents itself a risk factor for the development of glucose metabolism alterations. Therefore, routine oral glucose tolerance testing is warranted in these patients.

Angiotensin-converting enzyme activity in experimental alcoholic fatty liver of the rat.

Angiotensin-converting enzyme (ACE) activity was found increased in serum of patients with chronic alcoholism. We studied this enzymatic activity in serum and liver tissue of rats with alcoholic fatty liver due to prolonged intake of ethanol with a liquid diet, according to De Carli and Lieber. Serum and liver ACE activity did not show any significant increase in rats with alcoholic fatty liver when compared with controls, whereas gamma-glutamyltransferase activity exhibited a striking enhancement in serum and liver. Our data suggest that ACE is not an alcohol-induced enzyme in the experimental rat model.

Socioeconomic status and hypertension in children of two state schools in Naples, Italy: preliminary findings.

Most epidemiologic studies have shown a relationship between high blood pressure and socioeconomic status in childhood. Systolic and diastolic pressure were measured in 296 schoolboys and 338 schoolgirls aged 10 to 13 years. The presence of known and suspected risk factors for hypertension was evaluated by a standardized questionnaire consisting of two sections: one completed by the subjects and another by their parents. Descriptive analysis showed a lack of association between socioeconomic background, parental educational levels and childhood hypertension, a relatively strong association between a sedentary style of life and hypertension (p less than 0.001) and a statistically significant influence of maternal or paternal history of hypertension or diabetes in the sample studied (p less than 0.05). However, when all the variables were assessed by multiple correspondence analysis, two nuclei of schoolchildren were delimited. One was composed of hypertensive children with family histories of hypertension and/or diabetes mellitus who lead sedentary lives, live in large dwellings with a low crowding index and whose parents are better educated. The second nucleus was composed of normotensive subjects with opposite characteristics. The data obtained indicate that there may be a relationship between blood pressure in children and the socioeconomic status and educational level of their parents and suggest that these factors may have an impact on the child's blood pressure at a relatively young age.