Cost analysis of minimally invasive radical hysterectomy for cervical cancer performed by a single surgeon in an Italian center: an update in gynecologic oncological field

The objective of this study is to perform an economic analysis and examine the influence of procedural volume of our hospital, evaluating the accounting systems of Robotic radical hysterectomy (RRH) vs Laparoscopic radical hysterectomy (TLRH) in patients with cervical carcinoma, due to the costs widely variable and lack in literature. Costs were collected prospectively, from March 2010 to March 2016. Direct costs were determined by examining the overall medical pathway for each type of intervention. 52 patients with cervical carcinoma, which were matched by age, body mass index, tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, comorbidity, previous neoadjuvant chemotherapy, histology type, and tumor grade to obtain homogeneous samples. Surgical time was similar for both the groups. RRH was associated with a significantly less (EBL) estimated blood loss (P = 0.000). The overall median length of follow-up was of 59 months. The cost of the robot-specific supplies was €2705 per intervention. When considering overall medical surgical care, the patient treatment average cost of an RRH was €5650,31 with an hospital stay (HS) of 3.58 days (SD ± 1) vs €3750.86 for TRLH, with an HS of 4.27 days (SD ± 1.79). Our results are similar to Finnish data; the costs of robot-assisted hysterectomies were 1.5 times higher than TLRH. The main drivers of additional costs are robotic disposable instruments, which are not compensated by the hospital room costs and by an experienced team staff. Implementation of strategies to reduce the cost of robotic instrumentation is due. RRH resulted less expensive than robotic simple hysterectomy for benign conditions.     

Numerical Stability Analysis for a Stationary and Translating Droplet at Extremely Low Viscosity Values Using the Lattice Boltzmann Method Color-Gradient Multi-Component Model with Central Moments Formulation

Multicomponent models based on the Lattice Boltzmann Method (LBM) have clear advantages with respect to other approaches, such as good parallel performances and scalability and the automatic resolution of breakup and coalescence events. Multicomponent flow simulations are useful for a wide range of applications, yet many multicomponent models for LBM are limited in their numerical stability and therefore do not allow exploration of physically relevant low viscosity regimes. Here we perform a quantitative study and validations, varying parameters such as viscosity, droplet radius, domain size and acceleration for stationary and translating droplet simulations for the color-gradient method with central moments (CG-CM) formulation, as this method promises increased numerical stability with respect to the non-CM formulation. We focus on numerical stability and on the effect of decreasing grid-spacing, i.e. increasing resolution, in the extremely low viscosity regime for stationary droplet simulations. The effects of small- and large-scale anisotropy, due to grid-spacing and domain-size, respectively, are investigated for a stationary droplet. The effects on numerical stability of applying a uniform acceleration in one direction on the domain, i.e. on both the droplet and the ambient, is explored into the low viscosity regime, to probe the numerical stability of the method under dynamical conditions.     

Role of iron metabolism and oxidative damage in postmenopausal bone loss

It has been suggested that iron-deficient rats have lower bone mass than iron-replete animals, but a clear association between bone and iron repletion has not been demonstrated in humans. A growing body of evidences also suggests a relation between lipid oxidation and bone metabolism and between iron metabolism and LDL oxidation. Iron availability to cells also depends on haptoglobin (Hp) phenotypes. Hp has also important antioxidant properties according to its phenotype, hence we evaluate whether Hp phenotype could influence bone density, iron metabolism and lipid oxidation. This cross-sectional study enrolled 455 postmenopausal women affected by osteoporosis (260) or not (195). Bone mineral density, markers of bone and iron metabolism, levels of oxidized LDL (oxLDL) and Hp phenotype were measured in all the subjects. Hp 1.1 and 2.2 frequency was higher and Hp 2.1 was lower in the patients with fragility fractures (80) compared with the controls. We therefore evaluate different Hp phenotypes as risk or protective factors against fragility fracture: Hp 2.1 is a protective factor against fracture while 1.1 is an important and 2.2 a moderate risk factor for fragility fractures. Lower serum iron was associated with elevated transferrin in patients with Hp 1.1; moreover patients had relative iron deficiency compared with the controls and fractured patients had higher level of oxLDL. We found that both iron metabolism and oxLDL varies according to Hp phenotypes and are predictive of bone density. Our data indicate that Hp 2.1 is a protective factor for fragility fractures, depending on its role on iron metabolism and its antioxidant properties.     

Awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: a safe outpatient procedure.

OBJECTIVE: To verify the feasibility and compare the results of thoracoscopic sympathectomy under local anaesthesia (LA) and spontaneous breathing vs. general anaesthesia (GA) with one-lung ventilation. METHODS: Two groups of consecutive patients underwent one stage bilateral T2-T3 thoracoscopic sympathectomy under LA (n=15) and GA (n=30) by the same surgical team for treatment of primary palmar hyperhidrosis. The groups were homogeneous for relevant demographic, physiological and clinical data, including pulmonary function. In both groups, patient's satisfaction was evaluated 24h after surgery by a simple interview and scored into five grades (1=very poor to 5=excellent), while quality of life (QOL) was evaluated by SF-36 and Nottingham's Health Profile questionnaires before and 6 months after surgery. A cost comparison between groups concerning devices, drugs, global in operating room time, medical personnel and hospital stay was also carried out. RESULTS: No operative mortality was recorded. The overall in operating room time for the whole bilateral procedure under LA was 63.55+/-10.58 vs. 86.05+/-5.75 under GA (P<0.01) and temperature increased in all patients from a baseline of 25.42+/-0.56 up to 32.15+/-0.84 degrees C. All patients undergone LA were discharged the same day after a chest roentgenogram and a short stay in the outpatient clinic. Among them three patients (20%) experienced a minimal (<30%) pneumothorax that required no treatment, while five (33.3%) had a trunk compensatory sweating that spontaneously resolved on the long run. Patients undergoing GA were discharged after a mean stay of 1.38+/-0.6 days. Among these, eight (26.6%) had prolonged trunk compensatory sweating that did not persist longer than 3 months. At a follow-up of 7.16+/-2.97 months, QOL was significantly improved with no difference between groups. The overall rate of satisfaction was greater in the LA group (P<0.05). CONCLUSIONS: In our study, awake one stage bilateral thoracoscopic sympathectomy for palmar hyperhidrosis could be safely and effectively performed as an outpatient procedure in patients refusing GA. Postoperative quality of life was equal to that in patients undergone the same procedure under GA, while patient satisfaction was better and cost were significantly reduced.     

Minimally invasive video-assisted thyroidectomy in pediatric patients

Background

Minimally invasive video-assisted thyroidectomy (MIVAT) proved to be safe and effective in the treatment of both benign diseases and malignancies. We report our experience in thyroid surgery in pediatric patients.

Methods

From October 1998 to December 2005, 35 patients (27 females and 8 males) underwent MIVAT for thyroid disease. The mean age was 14.0 years (range, 8-18 years); mean ecographically estimated thyroid volume was 11.13 mL (range, 8-25 mL).

Results

A total thyroidectomy was performed in 22 patients, whereas lobectomy was performed in 13. Two patients of the latter group had a second lobectomy for a false-negative result at frozen section during the first operation. One patient underwent also a prophylactic central neck dissection for positive RET oncogene. The histologic examination found a papillary carcinoma in 11 patients, a microfollicular nodule in 7 patients, and multinodular goiter in 17 patients. The mean operative time was 54.1 minutes for thyroidectomy (range, 25-110 minutes) and 38.5 minutes for lobectomy (range, 20-65 minutes). All patients but one was discharged on the first postoperative day. One transient hypoparathyroidism was observed in the patient who underwent total thyroidectomy plus central neck lymphadenectomy.

Conclusions

The MIVAT technique proved to be as safe and effective as conventional thyroidectomy with Kocher approach to treat patients with both benign and malignant diseases of the thyroid gland. The advantages of MIVAT are represented by a better and faster postoperative course and an improved aesthetic result, which is particularly important in this group of patients.     

Comparison of angioplasty with infusion of tirofiban or abciximab and with implantation of sirolimus-eluting or uncoated stents for acute myocardial infarction: the MULTISTRATEGY randomized trial

Context  Abciximab infusion and uncoated-stent implantation is a complementary treatment strategy to reduce major adverse cardiac events in patients undergoing angioplasty for ST-segment elevation myocardial infarction (STEMI). It is uncertain whether there may be similar benefits in replacing abciximab with high-dose bolus tirofiban. Similarly, the use of drug-eluting stents in this patient population is currently discouraged because of conflicting results on efficacy reported in randomized trials and safety concerns reported by registries. Objective  To evaluate the effect of high-dose bolus tirofiban and of sirolimus-eluting stents as compared with abciximab infusion and uncoated-stent implantation in patients with STEMI undergoing percutaneous coronary intervention. Design, Setting, and Patients  An open-label, 2 x 2 factorial trial of 745 patients presenting with STEMI or new left bundle-branch block at 16 referral centers in Italy, Spain, and Argentina between October 2004 and April 2007. Interventions  High-dose bolus tirofiban vs abciximab infusion and sirolimus-eluting stent vs uncoated stent implantation. Main Outcome Measures  For drug comparison, at least 50% ST-segment elevation resolution at 90 minutes postintervention with a prespecified noninferiority margin of 9% difference (relative risk, 0.89); for stent comparison, the rate of major adverse cardiac events, defined as the composite of death from any cause, reinfarction, and clinically driven target-vessel revascularization within 8 months. Results  ST-segment resolution occurred in 302 of 361 patients (83.6%) who had received abciximab infusion and 308 of 361 (85.3%) who had received tirofiban infusion (relative risk, 1.020; 97.5% confidence interval, 0.958-1.086; P < .001 for noninferiority). Ischemic and hemorrhagic outcomes were similar in the tirofiban and abciximab groups. At 8 months, major adverse cardiac events occurred in 54 patients (14.5%) with uncoated stents and 29 (7.8%) with sirolimus stents (P = .004), predominantly reflecting a reduction of revascularization rates (10.2% vs 3.2%). The incidence of stent thrombosis was similar in the 2 stent groups. Conclusions  In patients with STEMI undergoing percutaneous coronary intervention, compared with abciximab, tirofiban therapy was associated with noninferior resolution of ST-segment elevation at 90 minutes following coronary intervention, whereas sirolimus-eluting stent implantation was associated with a significantly lower risk of major adverse cardiac events than uncoated stents within 8 months after intervention. Trial Registration  clinicaltrials.gov Identifier: NCT00229515      

Pseudoexfoliation syndrome: in vivo confocal microscopy analysis

Pseudoexfoliation (PEX) syndrome is a common ocular disease that also affects the cornea. A case of clinical PEX syndrome, studied by in vivo corneal confocal microscopy is reported. The morphological analysis of the confocal images demonstrated hyper-reflective deposits and several dendritic cells in the basal epithelial layer. A fibrillar subepithelial structure was also found. The endothelial layer showed cell anomalies (polymegathism and pleomorphism) and hyper-reflective small endothelial deposits. Confocal microscopy is an in vivo imaging method that may provide new information on corneal alterations in PEX, and detect early corneal features.     

Allergic contact dermatitis in hairdressers: frequency and source of sensitisation

Occupational skin diseases are very common among hairdressers. The aim of our study was to evaluate the frequency, the age distribution and the source of contact sensitization in a group of 209 hairdressers who consulted our Clinic from 1990 to 1999. One hundred and thirty-two patients showed one or more clinically relevant positive reactions to different allergens; 89 of them were positive to the hairdressers' series and 43 were positive to other allergens. Para-phenylenediamine base and para-toluenediamine sulphate caused the greatest number of positive reactions (77 and 29 respectively). Both glyceryl monothioglycolate and ammonium persulphate gave 25 positive patch tests. The allergens not included in the hairdressers' series which gave the greatest number of positive reactions were nickel sulphate and disperse dyes yellow 3, blue 124 and red 1. The allergens known as strong skin sensitizers have remained almost the same over the years. Preventive measures should be mandatory to protect hands and to improve the safety of this job.     

Repetitive deformation and pressure activate small bowel and colonic mucosal tyrosine kinase activity in vivo

Physical forces like deformation and pressure modulate signaling and phenotype in cultured cells. However, it is more difficult to establish that such phenomena occur in vivo. We studied the effects of 0 to 10 minutes of rhythmic distension with an isotonic electrolyte and polyethylene glycol solution to 30 cm H(2)O pressure on defunctionalized small and large bowel segments in adult male Sprague Dawley rats. Mucosa was harvested at 0, 1, and 10 minutes and assayed for tyrosine kinase activity. Rhythmic distension caused a time-dependent increase in colonic mucosal tyrosine kinase activity, which was statistically significant at 10 minutes (140% +/- 41% increase, n = 5, P <.05). Small bowel tyrosine kinase activity was markedly lower than that observed in the colon, but achieved a statistically significant increase at 5 minutes after initiation of rhythmic distension. (115% +/- 44% increase, n = 5, P <.05).