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.

Total rectosigmoidectomy versus partial rectal resection in primary debulking surgery for advanced ovarian cancer.

PURPOSE: To compare in a sample of Italian patients intraoperative, perioperative complications, Quality of Life (QoL), recurrence rate and overall survival of advanced ovarian cancer (AOC) patients according to the type of surgery performed on sigma-rectum, total rectosigmoid resection (TRR) versus partial rectosigmoid resection (PRR). METHODS: From May 2004 to May 2010, consecutive patients affected by epithelial AOC (FIGO Stage III-IV) were assessed for this prospective case-control study, According to the type of colorectal surgery performed to approach rectosigmoid involvement, patients were allocated into Group A (TRR) and Group B (PRR). PRR was performed when the complete removal of disease led to a laceration <30-40% of intestinal wall circumference. RESULTS: 82 and 72 patients were included in Group A and Group B respectively. Surgical outcomes were statistically similar except hospital stay which was significantly lower in the PRR group. There was not a statistically significant difference as regarding intra-operative, perioperative and postoperative complications, even if a higher rate of major complications were recorded in TRR. An improvement in QoL's scores has been recorded in PRR's group. There was not a statistically difference concerning the optimal debulking rate (92% and 96% respectively) and 5-year Overall Survival (48% and 52% respectively). CONCLUSIONS: PRR seems to be feasible in over 40% of patients with advanced ovarian cancer and recto-sigmoid colon involvement. It is related to higher QoL and can be easily performed, without jeopardizing surgical radicality, in those cases in which conservative surgery at intestinal tract does not compromise residual tumor.

Contrast-enhanced ultrasound of hepatocellular carcinoma: correlation between enhancement pattern and cellular differentiation on histopathlogy.

The aim of this study was to evaluate and correlate the enhancement pattern of hepatocellular carcinoma (HCC) on contrast-enhanced ultrasound (CEUS) and tumour cellular differentiation on histopathology. Patients underwent hepatic CEUS, performed with SonoVue and contrast pulse sequencing. The correlation between enhancement time and enhancement level of the lesions in different vascular phases and tumour cellular differentiation was determined. The tumours were graded according to the Edmondson grading system. Then, diagnosis was obtained by histopathological examination following surgery or percutaneous ultrasound-guided biopsy. 189 patients with HCC were examined with CEUS and histopathological examination between 2003 and 2009: 159 had a solitary lesion (85 %), 24 had 2 lesions (12 %) and 6 had multiple lesions (3 %). The final histological grading of the tumours was as follows: 22, 114, 49, 4 grade I-IV, respectively. Significant differences were shown between the time that HCC become hypoenhancing or remained echogenic in late phase and tumour cellular differentiation (p = 0.006, p = 0.036). The timing of HCC becoming hypoenhancing was correlated with tumour cellular differentiation, with better differentiated HCCs washing out more slowly than poorly differentiated ones (p = 0.164, p = 0.113; p = 0.186, p = 0.070). The enhancement pattern of HCC by CEUS correlates with the cellular differentiation. In late phases, hyperechoic lesions are likely to be better differentiated, whereas hypoechoic lesion is more likely to be poorly differentiated.

Monte Carlo simulation of the response of ESR dosimeters added with gadolinium exposed to thermal, epithermal and fast neutrons.

Monte Carlo numerical calculations of the response of alanine and ammonium tartrate ESR (electron spin resonance) dosimeters exposed to neutron fields with different energy spectra are reported. Results have been obtained for various gadolinium concentrations inside the dosimeters. Furthermore, in order to simulate the in-phantom response we have carried out calculations by varying the depth of the dosimeter. We have found that a large enhancement is obtained for thermal neutrons, because of the very high capture cross section of gadolinium to thermal neutrons. A good enhancement was obtained for epithermal neutrons, whereas the sensitivity improvement in the case of fast neutron irradiation is poor. Furthermore, the simulations carried out by varying the depth suggests that an appreciable sensitivity to thermal and epithermal neutrons could be observed for in-phantom measurements in the 2-3 cm depth range. These results can provide useful insight for future experiments with epithermal neutron beams (such as those used in neutron capture therapy) and for future applications in neutron capture therapy dosimetry.

Seasonal variation of air kerma rate in Sicily.

Thermoluminescence dosimetry has been used to measure air kerma in 29 sites in Sicily. Four three month measurement campaigns have been carried out in order to assess seasonal variations. Average annual values between 20 and 90 nGy h(-1), after cosmic background subtraction, are reported. Average annual values are strongly dependent on site lithology, and we find that winter data are generally the highest, while spring and autumn rates are generally the lowest with very similar trends in any site. Summer values generally lay in between. Largest seasonal variations are found in sites along the southern coast of the island, probably because of stronger action of winds affecting radon, along with its progeny, concentrations at ground level.

Bulky lymph node resection in patients with recurrent epithelial ovarian cancer: impact of surgery.

The aim of this study was to evaluate the role of systematic lymphadenectomy, feasibility, complications rate, and outcome in epithelial ovarian cancer (EOC) patients with recurrent bulky lymph node disease. A prospective observational study of EOC patients with pelvic/aortic lymph node relapse was conducted between January 1995 and June 2005. After a clinical and laparoscopic staging, secondary cytoreduction, including systematic lymphadenectomy, were performed. The eligibility criteria were as follows: disease-free interval > or =6 months, radiographic finding suggestive of bulky lymph node recurrence, and patients' consent to be treated with chemotherapy. Forty-eight EOC patients with lymph node relapse were recruited. Twenty-nine patients were amenable to cytoreductive surgery. Postoperatively, all patients received adjuvant treatment. The median numbers of resected aortic and pelvic nodes were 15 (2-32) and 17 (8-47), respectively. The median numbers of resected aortic and pelvic positive lymph nodes were 4 (1-18) and 3 (1-17), respectively. The mean size of bulky nodes was 3.3 cm. Four patients (14%) experienced one severe complication. No treatment-related deaths were observed. After a median follow-up of 26 months, among cytoreduced patients, 18 women were alive with no evidence of disease, nine were alive with disease. Among the 11 patients not amenable to surgery, five women were alive with persistent disease, six patients died of disease, at a median follow-up of 18 months. Estimated 5-year overall survival and disease-free interval for operated women were 87% and 31%, respectively. In conclusion, patients with bulky lymph node relapse can benefit from systematic lymphadenectomy in terms of survival. The procedure is feasible with an acceptable morbidity rate.

Gynecological cancers in developing countries: the challenge of chemotherapy in low-resources setting.

The epidemiologic pattern of cancers in developing countries differs in many aspects from that of industrialized nations. Cancer natural history, microbiologic environment, patient's immune system, and drug availability may differ as well. Four of five new cases of cervical cancer and most of cervical cancer deaths occur in developing countries. Where chemoradiation and supportive care facilities are unavailable, it would be logical to consider an inexpensive effective drug. In locally advanced cases, neoadjuvant chemotherapy followed by surgery should be considered the treatment of choice. For ovarian cancer, it may be reasonable to maintain a secure supply of platinum and/or taxanes. For endometrial cancer, platinum compounds are proved active chemotherapic single agents. Oral medroxyprogesterone acetate (MPA) may represent a good chance for treating an advanced or recurrent disease. For vulvar/vaginal cancer, the role of chemotherapy alone is currently considered limited, and it is mostly used as palliative treatment in advanced or recurrent cases. Whenever possible, standard western chemotherapic regimens should be applied in developing countries as well. When standard therapies are unavailable, drugs of choice should be easily accessible, inexpensive, and effective. The most commonly used drugs are cisplatin, cyclophosphamide, and MPA.

The pharmacokinetics and immunosuppressive response of tacrolimus in paediatric renal transplant recipients.

The aims of our trial were to study the pharmacokinetics of tacrolimus in paediatric kidney transplant recipients. The study comprised 25 patients (median age 13 years, range 2-20 years) followed for 12 months; five pharmacokinetics profiles (within the first and second week and after 1 month, 6 months and 12 months) were obtained. Patients were divided into two groups: six children<6 years old and 19 older children. Tacrolimus was given at an initial dose of 0.15 mg/kg twice a day. Blood samples were drawn before and 1 h, 2 h, 3 h, 4 h, 6 h, 9 h and 12 h after drug administration. Patient and kidney survival rates were 100% at 1 year. At 6 months and 12 months creatinine clearance was 68.5+/-16.3 ml/min per 1.73 m2 and 64.0+/-15.2 ml/min per 1.73 m2 body surface area, respectively. Tacrolimus trough levels were 7.8+/-1.9 ng/ml and 7.3+/-2.5 ng/ml. The area under the concentration-time curve for 0 h to 12 h (AUC0-12) normalised to a dose of 0.15 mg/kg, increased with time from the kidney transplantation and stabilised after the 6th month post-transplantation. During the first month after transplantation the normalised tacrolimus concentration-time profiles were significantly greater in the older children (P<0.05); the actual doses were significantly greater in the younger children (P<0.05). In conclusion, initial doses of 0.15 mg/kg twice a day orally are safe and guarantee a satisfactory degree of immunosuppression, with our therapeutic regimen. Children<6 years old need to start with a 50% higher tacrolimus dose to achieve the same pharmacokinetic and immunosuppressive results.

The role of neoadjuvant chemotherapy followed by radical surgery in the treatment of locally advanced cervical cancer.

In 1984 the first pilot study on neoadjuvant chemotherapy in cervical cancer was reported. Since then, many investigators have studied the possible role that this therapeutic strategy could achieve in patients. Different chemotherapic combinations are constantly being attempted in order to obtain the maximum tumour response. At the same time few randomised studies have demonstrated the superiority of this treatment when adopted before radical surgery, in terms of overall survival compared to radiotherapy alone. Recently a detailed meta-analysis has been performed and the results confirmed what previously was achieved by the randomised trials. Since the beginning of all the phase III trials, the standard treatment of locally advanced disease has been modified from radiotherapy alone to concomitant radio-chemotherapy. For this reason the EORTC group has launched a trial with the objective of comparing neoadjuvant chemotherapy followed by radical surgery versus concomitant chemo-radiotherapy.

Effects of Sequential Calcium Chloride, Ziram, and Yeast Orchard Sprays on Postharvest Decay of Pear.

The most effective nutritional, fungicidal, and biological control treatments previously evaluated for control of postharvest decay in pear were evaluated for 3 years as factorial treatments to determine the best combinations for an integrated program. Calcium chloride sprays during the growing season reduced incidence of side rot in each year and of blue mold in 1 year, while ziram was effective against side rot in 1 year and blue mold in 2 years. Ziram, but not calcium chloride, provided control of gray mold and bull's-eye rot. Application of the yeast Cryptococcus infirmominiatus to pear fruit 1 week before harvest at a concentration of 1.0 to 1.5 × 108 CFU/ml resulted in establishment of large populations of yeast on fruit surfaces, but did not reduce postharvest fungal decay incidence in 3 years of testing. In 1 year, ziram sprays applied 2 weeks before harvest significantly reduced yeast populations on fruit subsequently treated with C. infirmo-miniatus. Sequential treatments with calcium chloride and ziram are indicated in an integrated program to take advantage of their differential effectiveness to broaden the range of control of pear postharvest decay pathogens.

Environmental radioactivity at Stromboli (Aeolian Islands).

HPGe gamma spectrometry, thermoluminescence dosimetry, X-ray diffractometry and fluorescence techniques have been used to analyze the natural radionuclides content of soil and rock samples, air kerma and geochemical features on the island of Stromboli, belonging to the Aeolian Islands, in the Mediterranean Sea. The 214Bi, 238Ac, and 40K contents obtained are in agreement with the magmatic evolution of the rock formation, as shown by the correlations between radionuclide and chemical elements abundacies, depending on the various magmatic differentiation mechanisms. Correlations between radiometric, lithological and geochemical data have been assessed in order to obtain some hints on the geochronology of the magmatic products.

Gamma activity and geochemical features of building materials: estimation of gamma dose rate and indoor radon levels in Sicily.

A high-purity germanium detector has been used to measure the abundance of radium (Ra), thorium (Th) and potassium (K) in building materials used in Sicilian dwellings. The measurements were performed to evaluate which material was suitable for the construction of an enclosure, which would have a low background emission. The materials examined in this work showed concentrations of 226Ra, 232Th and 40K dramatically variable depending on the lithologies, particularly in the case of blocks, sands and aggregates commonly used in building materials in Sicily. The results are discussed and a criterion is indicated to reduce the radiation dose to humans. Since radon inlet is a major health problem, all the radiometric data and the geochemical features have been used to determine the radon exhalation, which arises from the disintegration of 226Ra in soils and walls of houses. From our experimental data it can be seen out that one of the geochemical parameters, Total Alkali (TA), may be an appropriate index to select materials of low radiological risk.

Seasonal variation of air kerma in the "Vulcano Porto" area (Aeolian Islands, Italy).

Air kerma was measured in the "Vulcano Porto" area of the Vulcano Island, belonging to the Aeolian Islands, in the Mediterranean Sea. Measurements were carried out using thermoluminescence dosimeters. The relationship between observed dose values and source lithology has been assessed. Data show a seasonal variation due to weather conditions but also probably related to features of the soils, making the variation more evident.

The relationship between axonal spike shape and functional modality in cutaneous C-fibres in the pig and rat.

Axonal spike shape was examined in identified cutaneous C-fibres dissected from the saphenous nerves of anaesthetized pigs and rats, and was found to vary with functional class. In the pig, the action potential duration for heat nociceptor units (duration at half peak amplitude, 1.25 +/- 0.16 ms, mean +/- S.E.M., n=32) was significantly longer than the duration for polymodal nociceptive units (0.88 +/- 0.11 ms, n=32). Both classes of nociceptive C-fibre had action potentials of longer duration than the low-threshold mechanoreceptor units (0.49 +/- 0.04 ms, n=24) and the inexcitable C-fibres (0.56 +/- 0.06 ms, n=19). Undershoot durations were also longer in nociceptive than non-nociceptive C-fibres. In contrast, spike amplitudes were similar in all classes of C-afferent. In the rat, as in the pig, the polymodal nociceptor units had action potentials of longer duration (0.75 +/- 0.05 ms, n=73) than the mechanoreceptor units (0.60 +/- 0.01 ms, n=23). C-fibres identified as spontaneously active sympathetic efferent units had wider action potentials (main initial peak: 1.01 +/- 0.12 ms, n=22; undershoot: 4.1 +/- 1.23 ms, n=20) than the afferent C-fibres (main peak: 0.69 +/- 0.03 ms, n=130; undershoot: 1.4 +/- 0.09 ms, n=111). All rat C-fibre types had action potentials with main initial peaks of a similar height. However, cold thermoreceptor units had spikes with significantly smaller undershoots compared to nociceptive or inexcitable C-fibres. It is concluded that there are clear differences in axonal spike shape between the different functional classes of C-fibre and, in particular, that nociceptive C-afferents tend to have axonal action potentials of longer duration than non-nociceptive afferents. The ion channels responsible for the longer duration action potentials may provide a target for the development of highly selective analgesic drugs.

A new, rapid, noninvasive screening test for celiac disease.

Serum levels of IgA and IgG antigliadin antibodies were evaluated in 267 subjects by using both the classic enzyme-linked immunosorbent assay and a rapid test (strip-AGA test) performed on a drop of whole blood. This new test was easy to perform and gave results comparable to those of the enzyme-linked immunosorbent assay; it could be useful in screening for celiac disease in both at-risk and normal populations.

Lowering plasma free fatty acid levels improves insulin action in conscious pregnant rabbits.

Acute elevation in plasma free fatty acid (FFA) levels in nonpregnant rabbits simulates some aspects of insulin resistance observed in late pregnancy. The aim of this study was therefore to evaluate whether lowered FFA induced by nicotinic acid (NA) infusion can improve insulin action in pregnant rabbits. To assess insulin sensitivity we applied euglycemic hyperinsulinemic clamp without (control study) or with concomitant NA infusion (NA study; infusion started 150 min before the glucose clamp) in conscious virgin and pregnant rabbits after an 18-h fast. A primed constant infusion of [3-3H]glucose was used to measure total glucose disposal and hepatic glucose production. Hyperinsulinemia, in association with NA infusion (NA study) brings about a significantly greater stimulation of total glucose disposal in both pregnant (approximately 30%) and nonpregnant (approximately 35%) rabbits compared with the control study. A more pronounced inhibition of hepatic glucose production occurred in NA study in pregnant rabbits (approximately 30 vs. approximately 10%) but it did not reach a statistical significance, whereas there was a total inhibition in nonpregnant rabbits. We conclude that acute decrease in plasma FFA levels mainly improves insulin action at the site of glucose utilization. These results therefore suggest that elevated FFA would contribute to the peripheral insulin resistance in late pregnancy.

Identification of multiple tachykinins in bovine adrenal medulla using an improved chromatographic procedure.

Comparison of data based on the reverse-phase HPLC with two ion-pairing reagents, trifluoroacetic acid (TFA) and heptafluorobutyric acid (HFBA), together with the use of two antibodies, has allowed us to identify the various tachykinins in the bovine adrenal medulla. The results show that substance P-like, neurokinin B-like, and neurokinin A-like (including its extended forms, neuropeptide K and neuropeptide gamma) immunoreactivity are present in the bovine adrenal medulla. The concentration of SP-like immunoreactivity in the adrenal medulla was found to be substantially higher than that of NKA-like and NKB-like immunoreactivity. The strategy described here, using radioimmunoassay combined with HPLC employing TFA and HFBA as the ion-pairing reagents, should be useful for the identification of tachykinins and other peptides in the central and peripheral nervous system.

Chromatographic evidence for the presence of multiple tachykinins in the bovine adrenal medulla.

Among the mammalian tachykinins, substance P (SP) has been shown to be the most potent at modulating the response due to nicotinic acetylcholine receptor stimulation of bovine adrenal chromaffin cells. SP-like immunoreactivity has been detected in nerve terminals innervating the adrenal medulla; however, little is known of the presence of other tachykinins in this tissue. In this study, reverse-phase HPLC was used to fractionate peptides in bovine adrenal medullary extracts, and the fractions were analyzed by radioimmunoassay using antisera to SP or neurokinin A (NKA). The results show that both NKA- and SP-like immunoreactivities are present in the adrenal medulla. The presence of neurokinin B is also indicated. The presence of multiple tachykinins in this tissue raises questions as to their functions in the adrenal medulla.